Provider Demographics
NPI:1386982254
Name:IKEDA, MARTIN (PH D)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:IKEDA
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 ADVENTURELAND DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-2237
Mailing Address - Country:US
Mailing Address - Phone:515-778-4378
Mailing Address - Fax:
Practice Address - Street 1:1860 NW 118TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8278
Practice Address - Country:US
Practice Address - Phone:515-778-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00808103T00000X
1-13-13506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst