Provider Demographics
NPI:1619900198
Name:IKEDA, STEPHEN CRAWFORD (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CRAWFORD
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 1:64 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4881
Mailing Address - Country:US
Mailing Address - Phone:617-847-1950
Mailing Address - Fax:617-774-1490
Practice Address - Street 1:64 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4881
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:617-774-1490
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA731332084P0800X, 2084P0802X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ11337OtherBLUE CROSS
MAJ11337Medicare ID - Type Unspecified
MAE91387Medicare UPIN