Provider Demographics
NPI:1508362971
Name:MOLETA, CHACE DONOVYNE IKAIKA (MD)
Entity Type:Individual
Prefix:
First Name:CHACE
Middle Name:DONOVYNE IKAIKA
Last Name:MOLETA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5865 FRIARS RD APT 3217
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-6020
Mailing Address - Country:US
Mailing Address - Phone:808-782-6489
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-5004
Practice Address - Country:US
Practice Address - Phone:619-543-8254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA166812207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program