MEDICARE: DAVID IKUDAYISI, MD, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME 87841	FL
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	ME 87841	FL

General Provider Information

NPI Number	:	1801892963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID IKUDAYISI, MD, PA

Provider Business Mailing Address
First Line	:	PO BOX 272450
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33688-2450
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3651B W WATERS AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-2783
Country	:	US
Telephone Number	:	813-932-9798
Fax Number	:	813-935-5178

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	MR. DAVID OMOTAYO IKUDAYISI
Credential	:	MD
Telephone Number	:	813-932-9798

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	10/30/2007

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