Provider Demographics
NPI:1861720815
Name:IVANOV, GENNADIY (MD)
Entity type:Individual
Prefix:
First Name:GENNADIY
Middle Name:
Last Name:IVANOV
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 1:520 BUSTLETON PIKE
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-6052
Mailing Address - Country:US
Mailing Address - Phone:215-631-3873
Mailing Address - Fax:215-631-3899
Practice Address - Street 1:520 BUSTLETON PIKE
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053
Practice Address - Country:US
Practice Address - Phone:215-631-3873
Practice Address - Fax:215-631-3899
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD454021207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA464979OtherMEDICARE NUMBER