Provider Demographics
NPI:1477216406
Name:IKEDA, CREIGHTON
Entity Type:Individual
Prefix:
First Name:CREIGHTON
Middle Name:
Last Name:IKEDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SCHOFIELD RD.
Mailing Address - Street 2:BLDG 1179, ROOM 1CC5
Mailing Address - City:FT. SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234
Mailing Address - Country:US
Mailing Address - Phone:210-808-2228
Mailing Address - Fax:
Practice Address - Street 1:3100 SCHOFIELD RD.
Practice Address - Street 2:BLDG 1179, ROOM 1CC5
Practice Address - City:FT. SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-808-2228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2148938225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant