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NPI Code Detail

MEDICARE: ALEXANDER TARO IWAMOTO MD

MEDICARE: ALEXANDER TARO IWAMOTO MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program
2208000000XPediatrics Physician92011GA

General Provider Information

NPI Number : 1417416611
Entity Type Code : Individual
Provider Name (Legal Business Name) : ALEXANDER TARO IWAMOTO MD
Provider Business Mailing Address
First Line : 1875 CENTURY BLVD NE STE 150
Second Line :
City : ATLANTA
State : GA
Zip : 30345-3323
Country : US
Telephone Number : 404-633-4595
Fax Number :
Provider Business Practice Location Address
First Line : 1875 CENTURY BLVD NE STE 150
Second Line :
City : ATLANTA
State : GA
Zip : 30345-3323
Country : US
Telephone Number : 404-633-4595
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/18/2019
Last Update Date : 03/16/2023

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