Provider Demographics
NPI:1104028364
Name:DASSENKO, IVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:DASSENKO
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 1:6810 CANYON ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-9024
Mailing Address - Country:US
Mailing Address - Phone:503-581-7379
Mailing Address - Fax:503-585-7816
Practice Address - Street 1:6810 CANYON ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-9024
Practice Address - Country:US
Practice Address - Phone:503-581-7379
Practice Address - Fax:503-585-7816
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6160208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORBGTVMedicare ID - Type Unspecified
C92478Medicare UPIN