Provider Demographics
NPI:1891751889
Name:IKEDA, THOMAS MASASHI (OTR L)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MASASHI
Last Name:IKEDA
Suffix:
Gender:M
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 RICHLAND DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-8008
Mailing Address - Country:US
Mailing Address - Phone:254-772-0118
Mailing Address - Fax:254-772-3883
Practice Address - Street 1:1200 RICHLAND DR
Practice Address - Street 2:SUITE G
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-8008
Practice Address - Country:US
Practice Address - Phone:254-772-0118
Practice Address - Fax:254-772-3883
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111726225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX456889Medicare ID - Type Unspecified