Provider Demographics
NPI:1750456323
Name:KAMIL, IVAN J (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:J
Last Name:KAMIL
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 1:2810 FORRESTER DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4662
Mailing Address - Country:US
Mailing Address - Phone:818-234-6317
Mailing Address - Fax:
Practice Address - Street 1:21555 OXNARD ST
Practice Address - Street 2:6G
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-4943
Practice Address - Country:US
Practice Address - Phone:818-234-6317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 31326305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization