Provider Demographics
NPI:1124099601
Name:ICHIKAWA, DOUGLAS J (DPM)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:J
Last Name:ICHIKAWA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 116TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3024
Mailing Address - Country:US
Mailing Address - Phone:425-283-5093
Mailing Address - Fax:425-283-5095
Practice Address - Street 1:1609 116TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3024
Practice Address - Country:US
Practice Address - Phone:425-283-5093
Practice Address - Fax:425-283-5095
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000422213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0231400OtherL&I
WA1124099601Medicaid
WA1124099601Medicaid
WA0231400OtherL&I