Healthcare Provider Details

I. General information

NPI: 1871104067
Provider Name (Legal Business Name): SATOSHI IKEDA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E HARDY ST
INGLEWOOD CA
90301-4011
US

IV. Provider business mailing address

17128 COLIMA RD # 1851
HACIENDA HEIGHTS CA
91745-6769
US

V. Phone/Fax

Practice location:
  • Phone: 310-680-8536
  • Fax:
Mailing address:
  • Phone: 562-521-0732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: