Basic Information
| Provider Information | |||||||||
| NPI: | 1750475117 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IKEDA | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | KIYO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 FLYING POINT RD | ||||||||
| Address2: | |||||||||
| City: | BRANFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064055703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034882296 | ||||||||
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| Practice Location | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037776508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 01/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | 028111 | CT | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 208000000X | 028111 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 028111 | 01 | CT | MEDICAL LICENSE | OTHER | 17724 | 01 | CT | CONTROLLED SUBSTANCE | OTHER | 001281112 | 05 | CT | MEDICAID | 38502 | 01 | CT | AMERICAN BOARD PEDIATRICS | OTHER | BI2124383 | 01 | CT | DEA | OTHER |