=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093554172
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVAYLO VESELINOV
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2024
-----------------------------------------------------
Last Update Date | 05/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 199 E WEBSTER ST
-----------------------------------------------------
City | COLUSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95932-0019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-619-0800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2005 N RIVINGTON WAY
-----------------------------------------------------
City | EAGLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83616-7484
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-717-5877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 95028573
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------