Provider Demographics
NPI:1043830813
Name:IKIGAI PHYSICIAN GROUP INC
Entity type:Organization
Organization Name:IKIGAI PHYSICIAN GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SISSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-496-1828
Mailing Address - Street 1:3429 RENNER DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3104
Mailing Address - Country:US
Mailing Address - Phone:707-726-2255
Mailing Address - Fax:707-949-9715
Practice Address - Street 1:3429 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3104
Practice Address - Country:US
Practice Address - Phone:707-726-2255
Practice Address - Fax:707-949-9715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-22
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA123456OtherFAMILY MEDICINE