Healthcare Provider Details

I. General information

NPI: 1124529797
Provider Name (Legal Business Name): IDA GHLICHLOO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 10/30/2022
Certification Date: 10/30/2022
Deactivation Date: 04/11/2022
Reactivation Date: 10/20/2022

III. Provider practice location address

9500 GILMAN DR
LA JOLLA CA
92093-1653
US

IV. Provider business mailing address

472 BISCAYNE AVE
FOSTER CITY CA
94404-3550
US

V. Phone/Fax

Practice location:
  • Phone: 650-271-9445
  • Fax:
Mailing address:
  • Phone: 650-288-8041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: