Healthcare Provider Details

I. General information

NPI: 1518641042
Provider Name (Legal Business Name): IVY JEAN VILIRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6065 MERIDIAN AVE STE 70
SAN JOSE CA
95120-2772
US

IV. Provider business mailing address

PO BOX 412307
BOSTON MA
02241-2307
US

V. Phone/Fax

Practice location:
  • Phone: 408-927-0871
  • Fax:
Mailing address:
  • Phone: 914-294-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number309922
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP025331T
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP036767T
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP22174
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: