Provider Demographics
NPI:1376300251
Name:PERDUE, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:PERDUE
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 1:433 HOPELAND ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-4029
Mailing Address - Country:US
Mailing Address - Phone:937-219-1386
Mailing Address - Fax:
Practice Address - Street 1:433 HOPELAND ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-4029
Practice Address - Country:US
Practice Address - Phone:937-219-1386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant