Provider Demographics
NPI:1528191004
Name:NAZARETH, IVOR J (MD)
Entity Type:Individual
Prefix:
First Name:IVOR
Middle Name:J
Last Name:NAZARETH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:PROBST BLDG SUITE 311
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-568-3563
Mailing Address - Fax:
Practice Address - Street 1:39000 BOB HOPE DRIVE
Practice Address - Street 2:PROBST BLDG 311
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270
Practice Address - Country:US
Practice Address - Phone:760-568-3563
Practice Address - Fax:760-346-9887
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA30151174400000X, 173000000X
CA301512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA25987Medicare UPIN