Healthcare Provider Details

I. General information

NPI: 1972967008
Provider Name (Legal Business Name): IVY HERNANDEZ GARDNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 CAPITOL AVE DEPT 402
SACRAMENTO CA
95816-6032
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-262-9500
  • Fax: 916-262-9502
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberA185167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: