Healthcare Provider Details

I. General information

NPI: 1962613430
Provider Name (Legal Business Name): RICHARD JAY IKEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 MADISON ST
JEFFERSON CITY MO
65101-5227
US

IV. Provider business mailing address

1125 MADISON ST
JEFFERSON CITY MO
65101-5227
US

V. Phone/Fax

Practice location:
  • Phone: 573-632-5525
  • Fax: 573-632-5811
Mailing address:
  • Phone: 573-632-5525
  • Fax: 573-632-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM2657
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR3B55
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1962613430
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: