Provider Demographics
NPI:1073539474
Name:BREED, IVAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:L
Last Name:BREED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4609
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-4609
Mailing Address - Country:US
Mailing Address - Phone:626-917-5999
Mailing Address - Fax:626-917-5999
Practice Address - Street 1:605 E BADILLO ST
Practice Address - Street 2:SUITE 110
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2846
Practice Address - Country:US
Practice Address - Phone:626-917-5999
Practice Address - Fax:626-917-5999
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA26426Medicare UPIN