Provider Demographics
NPI:1760532436
Name:IIDA, RICKEY (OD)
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:
Last Name:IIDA
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 1:4983 N BLACKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-0109
Mailing Address - Country:US
Mailing Address - Phone:559-229-7956
Mailing Address - Fax:559-221-2096
Practice Address - Street 1:2223 S MOONEY BLVD
Practice Address - Street 2:VISALIA MALL #820
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-6243
Practice Address - Country:US
Practice Address - Phone:559-739-8550
Practice Address - Fax:559-739-8636
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6053T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD006053Medicare ID - Type Unspecified
CAU69782Medicare UPIN