Healthcare Provider Details

I. General information

NPI: 1396206587
Provider Name (Legal Business Name): IAN CHRISTOPHER HOPPER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

IV. Provider business mailing address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

V. Phone/Fax

Practice location:
  • Phone: 707-559-7500
  • Fax:
Mailing address:
  • Phone: 707-559-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.074943
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A19517
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: