Provider Demographics
NPI:1891960076
Name:ANDERSON, IVAN (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:ANDERSON
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 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:3288 BELL RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603
Practice Address - Country:US
Practice Address - Phone:530-745-0700
Practice Address - Fax:530-745-0701
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15988207RC0000X
CAA110448207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
13566641OtherCAQH
NV1891960076Medicaid
NVV111311Medicare PIN
13566641OtherCAQH
NVV111313Medicare PIN