Provider Demographics
NPI:1346728573
Name:SMITH, IVAN SANFORD (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:SANFORD
Last Name:SMITH
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 1:6668 DANA POINT CV
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-5646
Mailing Address - Country:US
Mailing Address - Phone:561-865-2780
Mailing Address - Fax:
Practice Address - Street 1:6668 DANA POINT CV
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-5646
Practice Address - Country:US
Practice Address - Phone:561-865-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD011028E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine