Healthcare Provider Details

I. General information

NPI: 1710146543
Provider Name (Legal Business Name): KENSHO IWANAGA MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 PARNASSUS AVE C344
SAN FRANCISCO CA
94143-0632
US

IV. Provider business mailing address

521 PARNASSUS AVE C344
SAN FRANCISCO CA
94143-0632
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-2072
  • Fax: 415-476-9278
Mailing address:
  • Phone: 415-476-2072
  • Fax: 415-476-9278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA102487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: