Provider Demographics
NPI:1164604526
Name:IKUDAYISI, DAVID O (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:O
Last Name:IKUDAYISI
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 1:8019 N HIMES AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-2712
Mailing Address - Country:US
Mailing Address - Phone:813-932-9798
Mailing Address - Fax:
Practice Address - Street 1:6641 MADISON ST
Practice Address - Street 2:SUITE 3
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-1966
Practice Address - Country:US
Practice Address - Phone:727-232-0826
Practice Address - Fax:727-597-8487
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87841207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
43154ZMedicare PIN