Healthcare Provider Details

I. General information

NPI: 1356962781
Provider Name (Legal Business Name): DAVID IVANOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 COYLE AVE STE 212
CARMICHAEL CA
95608-6337
US

IV. Provider business mailing address

6620 COYLE AVE STE 212
CARMICHAEL CA
95608-6337
US

V. Phone/Fax

Practice location:
  • Phone: 916-536-9455
  • Fax:
Mailing address:
  • Phone: 916-536-9455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberA187113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: