Provider Demographics
NPI:1083872196
Name:IKEDA, MARC DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:DAVID
Last Name:IKEDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 BRUCEVILLE RD
Mailing Address - Street 2:MOB 3 - SUITE 233
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-4671
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6600 BRUCEVILLE RD
Practice Address - Street 2:MOB 3 - SUITE 233
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4671
Practice Address - Country:US
Practice Address - Phone:916-627-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-26
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105562208000000X, 207K00000X
PAMT200406207KA0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program