Basic Information
| Provider Information | |||||||||
| NPI: | 1891960076 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ANDERSON | ||||||||
| FirstName: | IVAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3288 BELL RD | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307450700 | ||||||||
| FaxNumber: | 5307450701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 05/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 15988 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | A110448 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 13566641 | 01 | CAQH | OTHER | 1891960076 | 05 | NV | MEDICAID |