Healthcare Provider Details

I. General information

NPI: 1023105954
Provider Name (Legal Business Name): JOHN IBARRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIELDS AVE
DAVIS CA
95616-5270
US

IV. Provider business mailing address

1112 EAGLE PL
DAVIS CA
95616-5700
US

V. Phone/Fax

Practice location:
  • Phone: 530-752-2300
  • Fax:
Mailing address:
  • Phone: 530-750-2299
  • Fax: 530-750-2408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: