Healthcare Provider Details

I. General information

NPI: 1275422040
Provider Name (Legal Business Name): PROF. ELAN IVY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2025
Last Update Date: 06/28/2025
Certification Date: 06/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 HAMILTON MILL RD STE 102
BUFORD GA
30519-4004
US

IV. Provider business mailing address

3300 HAMILTON MILL RD STE 102
BUFORD GA
30519-4004
US

V. Phone/Fax

Practice location:
  • Phone: 770-615-2364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: