Provider Demographics
NPI:1669421202
Name:HAMILTON, IVAN DEDRICK GAVIN (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:DEDRICK GAVIN
Last Name:HAMILTON
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 1:1700 MCHENRY AVE
Mailing Address - Street 2:STE 65B259
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4373
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:2351 CLAY ST
Practice Address - Street 2:SUITE 308
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-1931
Practice Address - Country:US
Practice Address - Phone:415-600-3458
Practice Address - Fax:415-600-3451
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD63437207R00000X
CAA104632207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408417900Medicaid
CAAV608ZOtherMEDICARE PTAN
CA1669421202Medicaid
CAAV608ZOtherMEDICARE PTAN
MDI39982Medicare UPIN
CA1669421202Medicaid