Provider Demographics
NPI:1316009103
Name:IRVINE, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:IRVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:100 STEIN PLZ
Mailing Address - Street 2:3-236
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-7065
Mailing Address - Country:US
Mailing Address - Phone:310-206-0485
Mailing Address - Fax:310-794-4930
Practice Address - Street 1:625 S FAIR OAKS AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2613
Practice Address - Country:US
Practice Address - Phone:626-817-4747
Practice Address - Fax:626-817-4702
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2015-01-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG59884207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA006598840Medicaid
CA006598840OtherBLUE SHIELD
CA180037512OtherMEDICARE RAILROAD
CA006598840Medicaid
CAWG59884BMedicare PIN
CAWG59884CMedicare PIN