Healthcare Provider Details

I. General information

NPI: 1083872196
Provider Name (Legal Business Name): MARC DAVID IKEDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2008
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 BRUCEVILLE RD MOB 3 - SUITE 233
SACRAMENTO CA
95823-4671
US

IV. Provider business mailing address

6600 BRUCEVILLE RD MOB 3 - SUITE 233
SACRAMENTO CA
95823-4671
US

V. Phone/Fax

Practice location:
  • Phone: 916-627-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA105562
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberMT200406
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA105562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: