Healthcare Provider Details

I. General information

NPI: 1346263670
Provider Name (Legal Business Name): KEN RAY IWAOKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 04/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CEDAR RD # 100
VISTA CA
92083-5102
US

IV. Provider business mailing address

10170 SORRENTO VALLEY RD
SAN DIEGO CA
92121-1604
US

V. Phone/Fax

Practice location:
  • Phone: 760-806-5400
  • Fax:
Mailing address:
  • Phone: 858-784-5888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA48630
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: