1902822745 NPI number — PAMELA K IKUTA DO

Table of content: PAMELA K IKUTA DO (NPI 1902822745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902822745 NPI number — PAMELA K IKUTA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IKUTA
Provider First Name:
PAMELA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1902822745
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4419
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODLAND HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91365-4419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-340-9988
Provider Business Mailing Address Fax Number:
818-587-2493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2175 ROSALINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96001-2509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-225-6000
Provider Business Practice Location Address Fax Number:
818-587-2493
Provider Enumeration Date:
07/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  20A7643 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 020A7643 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00127601 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00AX76430 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020A76430 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com