Basic Information
| Provider Information | |||||||||
| NPI: | 1609820604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IWAMOTO | ||||||||
| FirstName: | SATORI | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 MAUDE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014565368 | ||||||||
| FaxNumber: | 4014565782 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 MAUDE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562327 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 11161 | RI | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 9024198 | 05 | RI | MEDICAID |