Provider Demographics
NPI:1538147228
Name:IVANOVS, RAY (DPM)
Entity type:Individual
Prefix:DR
First Name:RAY
Middle Name:
Last Name:IVANOVS
Suffix:
Gender:M
Credentials:DPM
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 BROADWAY DEPARTMENT OF MANAGED CARE ROOM 2B 230
Mailing Address - Street 2:WOODHULL MEDICAL & MENTAL HEALTH CENTER
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206
Mailing Address - Country:US
Mailing Address - Phone:718-963-8000
Mailing Address - Fax:718-630-3122
Practice Address - Street 1:760 BROADWAY
Practice Address - Street 2:WOODHULL MEDICAL & MENTAL HEALTH CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206
Practice Address - Country:US
Practice Address - Phone:718-963-8000
Practice Address - Fax:973-442-1300
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYN004397213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ568091R4AMedicare PIN