=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003985466
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN G IWASA O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 W COURT ST
-----------------------------------------------------
City | WEISER
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83672-1941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-414-1600
-----------------------------------------------------
Fax | 208-414-1607
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 W COURT ST
-----------------------------------------------------
City | WEISER
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83672-1941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-414-1600
-----------------------------------------------------
Fax | 208-414-1607
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODD-649
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------