Healthcare Provider Details

I. General information

NPI: 1639444748
Provider Name (Legal Business Name): DEVIKA ICECREAMWALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEVIKA PATEL MD

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6605 NANCY RIDGE DR
SAN DIEGO CA
92121-2253
US

IV. Provider business mailing address

6605 NANCY RIDGE DR
SAN DIEGO CA
92121-2253
US

V. Phone/Fax

Practice location:
  • Phone: 858-900-2747
  • Fax: 858-750-2984
Mailing address:
  • Phone: 858-900-2747
  • Fax: 858-750-2984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number148974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: