Provider Demographics
NPI:1205802717
Name:DESERT NEUROLOGY MEDICAL GROUP
Entity type:Organization
Organization Name:DESERT NEUROLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVOR
Authorized Official - Middle Name:J
Authorized Official - Last Name:NAZARETH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-568-3563
Mailing Address - Street 1:39000 BOB HOPE DRIVE
Mailing Address - Street 2:PROBST BLDG 311
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270
Mailing Address - Country:US
Mailing Address - Phone:760-568-3563
Mailing Address - Fax:760-346-9887
Practice Address - Street 1:39000 BOB HOPE DRIVE
Practice Address - Street 2:PROBST BLDG 311
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270
Practice Address - Country:US
Practice Address - Phone:760-568-3563
Practice Address - Fax:760-346-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA301512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A301510Medicaid
ZZZ80841ZMedicare ID - Type Unspecified
CA00A301510Medicaid