Healthcare Provider Details

I. General information

NPI: 1932287794
Provider Name (Legal Business Name): LOUIS ALBERT IVEY III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MERCED ST
SAN LEANDRO CA
94577-4201
US

IV. Provider business mailing address

1320 EL CAPITAN DR STE 120
DANVILLE CA
94526-6260
US

V. Phone/Fax

Practice location:
  • Phone: 510-454-1000
  • Fax:
Mailing address:
  • Phone: 925-334-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG76248
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: