Healthcare Provider Details

I. General information

NPI: 1205253887
Provider Name (Legal Business Name): IKUYO IMAYAMA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6473 KINGSTON PIKE
KNOXVILLE TN
37919-4832
US

IV. Provider business mailing address

PO BOX 207830
DALLAS TX
75320-7830
US

V. Phone/Fax

Practice location:
  • Phone: 865-588-8841
  • Fax: 865-588-8841
Mailing address:
  • Phone: 888-412-2649
  • Fax: 405-792-8910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number70556
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number036139811
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number70556
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: