Provider Demographics
NPI:1184229577
Name:EAST IVY PANACEA INC
Entity Type:Organization
Organization Name:EAST IVY PANACEA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SARBANI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAITRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-442-5326
Mailing Address - Street 1:16320 ALEXANDER CT
Mailing Address - Street 2:
Mailing Address - City:MONTE SERENO
Mailing Address - State:CA
Mailing Address - Zip Code:95030-5204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2516 SAMARITAN DR STE B
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4108
Practice Address - Country:US
Practice Address - Phone:408-442-5326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty