Provider Demographics
NPI:1073729497
Name:IVOR H. HAREWOOD, M.D, FACS AMC
Entity Type:Organization
Organization Name:IVOR H. HAREWOOD, M.D, FACS AMC
Other - Org Name:REGENT SPECIALISTS MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVOR
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAREWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-296-6942
Mailing Address - Street 1:PO BOX 8387
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-0387
Mailing Address - Country:US
Mailing Address - Phone:323-296-6942
Mailing Address - Fax:323-299-1651
Practice Address - Street 1:3701 STOCKER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-5108
Practice Address - Country:US
Practice Address - Phone:323-296-6942
Practice Address - Fax:323-299-1651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23311261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G233110Medicaid
CA00G233110Medicaid