Provider Demographics
NPI:1093120701
Name:IVANOV, RADOSLAV (OD)
Entity Type:Individual
Prefix:
First Name:RADOSLAV
Middle Name:
Last Name:IVANOV
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N 17TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-5034
Mailing Address - Country:US
Mailing Address - Phone:610-969-3070
Mailing Address - Fax:610-969-3073
Practice Address - Street 1:401 N 17TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-5034
Practice Address - Country:US
Practice Address - Phone:610-969-3070
Practice Address - Fax:610-969-3073
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002925152W00000X, 152WL0500X, 152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy