Healthcare Provider Details

I. General information

NPI: 1285649863
Provider Name (Legal Business Name): NICHOLAS GREGORY IWASKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 11/10/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 CEDARBRUSH DR
DALLAS TX
75229-2901
US

IV. Provider business mailing address

4420 CEDARBRUSH DR
DALLAS TX
75229-2901
US

V. Phone/Fax

Practice location:
  • Phone: 352-222-7431
  • Fax: 972-542-6915
Mailing address:
  • Phone: 352-222-7431
  • Fax: 972-542-6915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberL3347
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: