Healthcare Provider Details

I. General information

NPI: 1215244041
Provider Name (Legal Business Name): GREGORY IWAASA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N 9TH ST
BISMARCK ND
58501-4530
US

IV. Provider business mailing address

401 N 9TH ST.
BISMARCK ND
58504-4530
US

V. Phone/Fax

Practice location:
  • Phone: 701-530-6000
  • Fax:
Mailing address:
  • Phone: 701-530-6000
  • Fax: 701-530-6407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC006202
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: