Healthcare Provider Details

I. General information

NPI: 1184994147
Provider Name (Legal Business Name): STEVEN G IWASA OD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 01/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 W COURT ST
WEISER ID
83672-1941
US

IV. Provider business mailing address

36 W COURT ST
WEISER ID
83672-1941
US

V. Phone/Fax

Practice location:
  • Phone: 208-414-1600
  • Fax: 208-414-1607
Mailing address:
  • Phone: 208-414-1600
  • Fax: 208-414-1607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODD649
License Number StateID

VIII. Authorized Official

Name: DR. STEVEN G IWASA
Title or Position: OPTOMETRIST
Credential: OD
Phone: 208-414-1600