Healthcare Provider Details

I. General information

NPI: 1861389397
Provider Name (Legal Business Name): BRANDEN Y ITOTANI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 W 9TH ST
WATERLOO IA
50702-5401
US

IV. Provider business mailing address

3421 W 9TH ST
WATERLOO IA
50702-5401
US

V. Phone/Fax

Practice location:
  • Phone: 319-272-2112
  • Fax:
Mailing address:
  • Phone: 319-272-2112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number131939
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: