Healthcare Provider Details

I. General information

NPI: 1811200124
Provider Name (Legal Business Name): KATRINA TAN IBONIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 01/11/2026
Certification Date: 01/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL # SE21
MADERA CA
93636-8762
US

IV. Provider business mailing address

39000 BOB HOPE DR
RANCHO MIRAGE CA
92270-3221
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-8769
  • Fax: 559-353-5580
Mailing address:
  • Phone: 760-340-3911
  • Fax: 760-834-7874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number45903
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberM-2029
License Number StateGU
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA165664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: