Provider Demographics
NPI:1043474596
Name:IMMERMAN, IGOR (MD)
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:IMMERMAN
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 1:1500 OWENS ST
Mailing Address - Street 2:CAMPUS BOX 3004
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94158-2334
Mailing Address - Country:US
Mailing Address - Phone:415-353-7584
Mailing Address - Fax:415-353-7200
Practice Address - Street 1:1500 OWENS ST
Practice Address - Street 2:CAMPUS BOX 3004
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94158-2334
Practice Address - Country:US
Practice Address - Phone:415-353-7584
Practice Address - Fax:415-353-7200
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119472207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA119472OtherMEDICAL LICENSE
CAP01412212OtherRAILROAD MEDICARE
CACA129967Medicare PIN
CAA119472OtherMEDICAL LICENSE
CACA129966Medicare PIN