Provider Demographics
NPI:1912905472
Name:IVANCICH, LARRY
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:
Last Name:IVANCICH
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:LARRY
Other - Middle Name:M
Other - Last Name:IVANCICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 660025
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0025
Mailing Address - Country:US
Mailing Address - Phone:626-401-2775
Mailing Address - Fax:626-401-9826
Practice Address - Street 1:11800 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-3040
Practice Address - Country:US
Practice Address - Phone:626-401-2775
Practice Address - Fax:626-401-9826
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2008-02-25
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CAE3249213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1092300001Medicare NSC
CAT19289Medicare UPIN