Healthcare Provider Details

I. General information

NPI: 1669421202
Provider Name (Legal Business Name): IVAN DEDRICK GAVIN HAMILTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2351 CLAY ST SUITE 308
SAN FRANCISCO CA
94115-1931
US

IV. Provider business mailing address

1700 MCHENRY AVE STE 65B259
MODESTO CA
95350-4373
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-3458
  • Fax: 415-600-3451
Mailing address:
  • Phone: 209-579-5628
  • Fax: 209-579-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD63437
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA104632
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: