Provider Demographics
NPI:1245220730
Name:IVANOVIC, LOU V (MD, FACC)
Entity Type:Individual
Prefix:
First Name:LOU
Middle Name:V
Last Name:IVANOVIC
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 E BELL RD STE 3100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2136
Mailing Address - Country:US
Mailing Address - Phone:602-494-3656
Mailing Address - Fax:602-867-3862
Practice Address - Street 1:3805 E BELL RD STE 3100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2136
Practice Address - Country:US
Practice Address - Phone:602-867-8644
Practice Address - Fax:602-606-5128
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ62323207RC0000X, 207RC0000X
CAC139863207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36073485Medicaid
ILE34818Medicare UPIN