Provider Demographics
NPI:1669478228
Name:IVAN L BREED MD INC
Entity Type:Organization
Organization Name:IVAN L BREED MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BREED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-917-5999
Mailing Address - Street 1:PO BOX 4609
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-4609
Mailing Address - Country:US
Mailing Address - Phone:626-917-5999
Mailing Address - Fax:626-917-5999
Practice Address - Street 1:605 E BADILLO ST
Practice Address - Street 2:SUITE 110
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2846
Practice Address - Country:US
Practice Address - Phone:626-917-5999
Practice Address - Fax:626-917-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA31294AMedicare ID - Type Unspecified
A26426Medicare UPIN