Provider Demographics
NPI:1326203266
Name:IKEDA, TAKEHISA (MD)
Entity type:Individual
Prefix:DR
First Name:TAKEHISA
Middle Name:
Last Name:IKEDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3278
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77588-3278
Mailing Address - Country:US
Mailing Address - Phone:713-464-9776
Mailing Address - Fax:713-464-9771
Practice Address - Street 1:1140 BUSINESS CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-2742
Practice Address - Country:US
Practice Address - Phone:713-464-9774
Practice Address - Fax:713-464-9771
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0117208000000X, 208M00000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205456101Medicaid