Provider Demographics
NPI:1932287794
Name:IVEY, LOUIS ALBERT III (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:ALBERT
Last Name:IVEY
Suffix:III
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 1:1320 EL CAPITAN DR
Mailing Address - Street 2:STE 120
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-6260
Mailing Address - Country:US
Mailing Address - Phone:925-334-5800
Mailing Address - Fax:
Practice Address - Street 1:2500 MERCED ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4201
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76248208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G762480Medicaid
F62428Medicare UPIN
00G762480Medicare ID - Type Unspecified