Healthcare Provider Details

I. General information

NPI: 1528474103
Provider Name (Legal Business Name): IVY CAO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1971 UNIVERSITY AVE FAMILY MEDICINE DEPARTMENT
RIVERSIDE CA
92507
US

IV. Provider business mailing address

1971 UNIVERSITY AVE
RIVERSIDE CA
92507-5202
US

V. Phone/Fax

Practice location:
  • Phone: 951-384-6200
  • Fax: 858-634-6959
Mailing address:
  • Phone: 951-384-6200
  • Fax: 951-213-3449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA144062
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: