1811385081 NPI number — MARCOS HIROSHI IKEDA PA

Table of content: (NPI 1811385081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811385081 NPI number — MARCOS HIROSHI IKEDA PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARCOS HIROSHI IKEDA PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BELLISSIMA WOMENS CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811385081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 W LITTLE YORK RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77076-1349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-692-0600
Provider Business Mailing Address Fax Number:
713-699-9352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 W LITTLE YORK RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77076-1349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-692-0600
Provider Business Practice Location Address Fax Number:
713-699-9352
Provider Enumeration Date:
12/22/2014

Additional Information

Authorized Official

Authorized Official Last Name:
IKEDA
Authorized Official First Name:
MARCOS
Authorized Official Middle Name:
HIROSHI
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
713-692-0600

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X , with the licence number:  N6375 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 213947901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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