Provider Demographics
NPI:1124694443
Name:ACAYAN, IVAN KIRK TOLOD (DPT)
Entity type:Individual
Prefix:
First Name:IVAN KIRK
Middle Name:TOLOD
Last Name:ACAYAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 MISSION ST UNIT 1212
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-1578
Mailing Address - Country:US
Mailing Address - Phone:619-980-1935
Mailing Address - Fax:
Practice Address - Street 1:1717 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-6756
Practice Address - Country:US
Practice Address - Phone:408-957-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300242225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty