Provider Demographics
NPI:1790026011
Name:IVANOV, YURIY OLEGOVICH (DO)
Entity type:Individual
Prefix:
First Name:YURIY
Middle Name:OLEGOVICH
Last Name:IVANOV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 NORTHERN BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3053
Mailing Address - Country:US
Mailing Address - Phone:516-321-6410
Mailing Address - Fax:
Practice Address - Street 1:125 PATERSON ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1962
Practice Address - Country:US
Practice Address - Phone:732-235-7661
Practice Address - Fax:732-235-7246
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2763962081P2900X
NJ1790026011208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty