Healthcare Provider Details

I. General information

NPI: 1336233493
Provider Name (Legal Business Name): IFEOMA IKENZE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 SIR FRANCIS DRAKE BLVD
SAN ANSELMO CA
94960
US

IV. Provider business mailing address

915 SIR FRANCIS DRAKE BLVD
SAN ANSELMO CA
94960
US

V. Phone/Fax

Practice location:
  • Phone: 415-258-9600
  • Fax: 415-258-9691
Mailing address:
  • Phone: 415-258-9600
  • Fax: 415-258-9691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG066491
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: