Provider Demographics
NPI:1003837410
Name:IVANITSKY, MICHAEL MSTISLAVOVICH (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:MSTISLAVOVICH
Last Name:IVANITSKY
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 1:940 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423-1666
Mailing Address - Country:US
Mailing Address - Phone:541-396-3111
Mailing Address - Fax:541-396-8135
Practice Address - Street 1:940 E 5TH ST
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1699
Practice Address - Country:US
Practice Address - Phone:541-396-3111
Practice Address - Fax:541-396-8135
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22589207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR288121Medicaid
ORF84579Medicare UPIN
OR107806Medicare ID - Type Unspecified