Provider Demographics
NPI:1194869131
Name:IWAMOTO, DENIS T (OD)
Entity type:Individual
Prefix:DR
First Name:DENIS
Middle Name:T
Last Name:IWAMOTO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9186 MIRA MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4804
Mailing Address - Country:US
Mailing Address - Phone:858-566-6262
Mailing Address - Fax:858-566-6318
Practice Address - Street 1:9186 MIRA MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4804
Practice Address - Country:US
Practice Address - Phone:858-566-6262
Practice Address - Fax:858-566-6318
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7497T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU13903Medicare UPIN
CACS052AMedicare PIN
CAOP7497Medicare ID - Type Unspecified