Provider Demographics
NPI:1043453749
Name:CALDERON, IVAN ALEJANDRO (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:ALEJANDRO
Last Name:CALDERON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-937-3864
Mailing Address - Fax:502-937-1237
Practice Address - Street 1:6801 DIXIE HWY
Practice Address - Street 2:SUITE 133
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-3913
Practice Address - Country:US
Practice Address - Phone:502-937-3864
Practice Address - Fax:502-937-1237
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYFT436207Q00000X
KY45462207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100137250Medicaid
KYK053760Medicare Oscar/Certification
KYP01103017Medicare PIN