Provider Demographics
NPI:1235282690
Name:IVANOV, ALFRED
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:IVANOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 TENNESSEE DR APT 206
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-2368
Mailing Address - Country:US
Mailing Address - Phone:630-544-7336
Mailing Address - Fax:
Practice Address - Street 1:7440 TENNESSEE DR APT 206
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-2368
Practice Address - Country:US
Practice Address - Phone:630-544-7336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist