Provider Demographics
NPI:1285665992
Name:ICHIKAWA, MARK S (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:ICHIKAWA
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 1:596 E EL CAMINO REAL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-1940
Mailing Address - Country:US
Mailing Address - Phone:408-245-6212
Mailing Address - Fax:
Practice Address - Street 1:596 E EL CAMINO REAL
Practice Address - Street 2:SUITE 2
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-1940
Practice Address - Country:US
Practice Address - Phone:408-245-6212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7965T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0079650Medicare PIN
CAU20572Medicare UPIN