Provider Demographics
NPI:1609763721
Name:ICPMD
Entity type:Organization
Organization Name:ICPMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MERVAT
Authorized Official - Middle Name:
Authorized Official - Last Name:KELADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-562-6633
Mailing Address - Street 1:1001 BLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-2308
Mailing Address - Country:US
Mailing Address - Phone:760-562-6633
Mailing Address - Fax:760-768-5037
Practice Address - Street 1:207 E BARIONI BLVD STE A
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-1620
Practice Address - Country:US
Practice Address - Phone:760-355-2999
Practice Address - Fax:760-768-5037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-20
Last Update Date:2025-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty