Provider Demographics
NPI:1275675852
Name:THOMAS, IVAN (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CENTURY PARK E STE 501
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2008
Mailing Address - Country:US
Mailing Address - Phone:310-203-8297
Mailing Address - Fax:310-203-8816
Practice Address - Street 1:2080 CENTURY PARK E STE 501
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2008
Practice Address - Country:US
Practice Address - Phone:310-203-8297
Practice Address - Fax:310-203-8816
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA36556174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist