Healthcare Provider Details

I. General information

NPI: 1588656144
Provider Name (Legal Business Name): CRAIG L IWAMOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SHADOW LN
LAS VEGAS NV
89102-2314
US

IV. Provider business mailing address

1111 SHADOW LN
LAS VEGAS NV
89102-2314
US

V. Phone/Fax

Practice location:
  • Phone: 702-383-4040
  • Fax: 702-383-0526
Mailing address:
  • Phone: 702-383-4040
  • Fax: 702-383-0526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9760
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: