Provider Demographics
NPI:1548229750
Name:IIDA, CALVIN T (MD)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:T
Last Name:IIDA
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 1:832 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1155 MILL ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1576
Practice Address - Country:US
Practice Address - Phone:775-982-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8307207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016160Medicaid
NV201660021Medicaid
NV002016160Medicaid
NVV100977Medicare ID - Type Unspecified