Provider Demographics
NPI:1619901352
Name:IKEDA, OSAMU (OD)
Entity Type:Individual
Prefix:
First Name:OSAMU
Middle Name:
Last Name:IKEDA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8751 VALLEY VIEW ST
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3566
Mailing Address - Country:US
Mailing Address - Phone:714-827-7191
Mailing Address - Fax:714-827-8191
Practice Address - Street 1:8751 VALLEY VIEW ST
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3566
Practice Address - Country:US
Practice Address - Phone:714-827-7191
Practice Address - Fax:714-827-8191
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6054T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist