Healthcare Provider Details

I. General information

NPI: 1265878797
Provider Name (Legal Business Name): KEVIN IKUTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 SENECA ST
SEATTLE WA
98101-2742
US

IV. Provider business mailing address

925 SENECA ST
SEATTLE WA
98101-2742
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-6600
  • Fax:
Mailing address:
  • Phone: 206-223-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number54992
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60816200
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: