Provider Demographics
NPI:1013422757
Name:CALVERT, IDALIS RAE
Entity Type:Individual
Prefix:
First Name:IDALIS
Middle Name:RAE
Last Name:CALVERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243511 W HIGHWAY 101
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98363-9472
Mailing Address - Country:US
Mailing Address - Phone:360-565-7264
Mailing Address - Fax:360-452-6274
Practice Address - Street 1:243511 W HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98363-9472
Practice Address - Country:US
Practice Address - Phone:360-565-7264
Practice Address - Fax:360-452-6274
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG607693432083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine