Healthcare Provider Details

I. General information

NPI: 1801892963
Provider Name (Legal Business Name): DAVID IKUDAYISI, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3651B W WATERS AVE
TAMPA FL
33614-2783
US

IV. Provider business mailing address

PO BOX 272450
TAMPA FL
33688-2450
US

V. Phone/Fax

Practice location:
  • Phone: 813-932-9798
  • Fax: 813-935-5178
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME 87841
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME 87841
License Number StateFL

VIII. Authorized Official

Name: MR. DAVID OMOTAYO IKUDAYISI
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 813-932-9798