Healthcare Provider Details

I. General information

NPI: 1922177351
Provider Name (Legal Business Name): JAN LEI IWATA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E SUPERIOR ST 307
CHICAGO IL
60611-2507
US

IV. Provider business mailing address

4600 N CLARENDON AVE 1202
CHICAGO IL
60640-5710
US

V. Phone/Fax

Practice location:
  • Phone: 773-501-7394
  • Fax: 773-296-7787
Mailing address:
  • Phone: 773-501-7394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number7541
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number7541
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number7541
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036-105234
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number036-105234
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number036-105234
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: