Provider Demographics
NPI:1750577219
Name:IWASA, DANIEL E (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:E
Last Name:IWASA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:925 NW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-5044
Mailing Address - Country:US
Mailing Address - Phone:208-452-2151
Mailing Address - Fax:208-452-6508
Practice Address - Street 1:915 3RD AVE N
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2403
Practice Address - Country:US
Practice Address - Phone:208-642-2151
Practice Address - Fax:208-642-7374
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-856152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000930900Medicaid