Provider Demographics
NPI:1548232556
Name:IKEDA, CLYDE J (MD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:J
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 1:1199 BUSH ST
Mailing Address - Street 2:STE 640
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109
Mailing Address - Country:US
Mailing Address - Phone:415-775-1199
Mailing Address - Fax:415-775-0360
Practice Address - Street 1:1199 BUSH ST
Practice Address - Street 2:STE 640
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109
Practice Address - Country:US
Practice Address - Phone:415-775-1199
Practice Address - Fax:415-775-0360
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49242208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7759618Medicaid
CA7759618Medicaid
CAA51307Medicare UPIN