Provider Demographics
NPI:1124207279
Name:SPECTOR, IVAN C (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:C
Last Name:SPECTOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IVAN
Other - Middle Name:C
Other - Last Name:SPECTOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3100 WESLAYAN ST
Mailing Address - Street 2:#350
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-5727
Mailing Address - Country:US
Mailing Address - Phone:713-963-0769
Mailing Address - Fax:713-963-8536
Practice Address - Street 1:3100 WESLAYAN ST
Practice Address - Street 2:#350
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-5727
Practice Address - Country:US
Practice Address - Phone:713-963-0769
Practice Address - Fax:713-963-8536
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-25
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG56332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC22101Medicare UPIN
TX00F89FMedicare PIN