Healthcare Provider Details

I. General information

NPI: 1568088110
Provider Name (Legal Business Name): IVAN ERNESTO LEROUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 12/22/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 E 7TH ST FL 2
UPLAND CA
91786-6740
US

IV. Provider business mailing address

1701 S FIGUEROA ST # 1434
LOS ANGELES CA
90015-3419
US

V. Phone/Fax

Practice location:
  • Phone: 800-213-8517
  • Fax:
Mailing address:
  • Phone: 464-322-9916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA183662
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: