Provider Demographics
NPI:1417399890
Name:IWAI, BENJAMIN TATSUNORI (OD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:TATSUNORI
Last Name:IWAI
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 1:313 N ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-1757
Mailing Address - Country:US
Mailing Address - Phone:319-758-9145
Mailing Address - Fax:
Practice Address - Street 1:313 N ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-1757
Practice Address - Country:US
Practice Address - Phone:319-758-9145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002605152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist