Healthcare Provider Details

I. General information

NPI: 1053623934
Provider Name (Legal Business Name): FABIO M IWAMOTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 W 168TH ST
NEW YORK NY
10032-3726
US

IV. Provider business mailing address

710 W 168TH ST
NEW YORK NY
10032-3726
US

V. Phone/Fax

Practice location:
  • Phone: 212-342-0571
  • Fax: 212-342-1246
Mailing address:
  • Phone: 212-342-0571
  • Fax: 212-342-1246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number264009
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: