Provider Demographics
NPI:1912580531
Name:SUAREZ, IVAN JON (DPM)
Entity type:Individual
Prefix:DR
First Name:IVAN JON
Middle Name:
Last Name:SUAREZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:IVAN
Other - Middle Name:
Other - Last Name:SUAREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:11301 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073-1003
Mailing Address - Country:US
Mailing Address - Phone:310-478-3711
Mailing Address - Fax:
Practice Address - Street 1:6601 RUGBY AVE STE 100
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4040
Practice Address - Country:US
Practice Address - Phone:323-749-9770
Practice Address - Fax:323-749-9771
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-02
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5974213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery