Basic Information
| Provider Information | |||||||||
| NPI: | 1386091585 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IWAKI | ||||||||
| FirstName: | KOSUKE | ||||||||
| MiddleName: | KEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1303 E HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594505611 | ||||||||
| FaxNumber: | 5594507470 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 E HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594505611 | ||||||||
| FaxNumber: | 5594507470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2016 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A162107 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.