Basic Information
| Provider Information | |||||||||
| NPI: | 1730124520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IKEDA | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | PHILIP | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 ETHAN WAY | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166793590 | ||||||||
| FaxNumber: | 9164823647 | ||||||||
| Practice Location | |||||||||
| Address1: | 1508 ALHAMBRA BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958166510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163251040 | ||||||||
| FaxNumber: | 9166694100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | G44382 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RP1001X | G44382 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | G44382 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00443820 | 05 | CA | MEDICAID |