Provider Demographics
NPI:1639444748
Name:ICECREAMWALA, DEVIKA (MD)
Entity type:Individual
Prefix:
First Name:DEVIKA
Middle Name:
Last Name:ICECREAMWALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEVIKA
Other - Middle Name:
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6605 NANCY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2253
Mailing Address - Country:US
Mailing Address - Phone:858-900-2747
Mailing Address - Fax:858-750-2984
Practice Address - Street 1:6605 NANCY RIDGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2253
Practice Address - Country:US
Practice Address - Phone:858-900-2747
Practice Address - Fax:858-750-2984
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA148974207N00000X, 207N00000X
MI4301103562207NP0225X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics