Healthcare Provider Details

I. General information

NPI: 1710988662
Provider Name (Legal Business Name): IVY-JOAN ERINMA MADU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 04/16/2022
Certification Date: 04/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 610
ORANGE CA
92868-3857
US

IV. Provider business mailing address

PO BOX 1693
ORANGE CA
92856-0693
US

V. Phone/Fax

Practice location:
  • Phone: 714-639-1815
  • Fax: 714-639-2374
Mailing address:
  • Phone: 714-639-1815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA50150
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: