Provider Demographics
NPI:1386669471
Name:DAVID, IVAN (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:DAVID
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 1:1912 TRADD CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6637
Mailing Address - Country:US
Mailing Address - Phone:910-251-3766
Mailing Address - Fax:910-251-3760
Practice Address - Street 1:1912 TRADD COURT
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6637
Practice Address - Country:US
Practice Address - Phone:910-251-3766
Practice Address - Fax:910-251-3760
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33495208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
213320AMedicare ID - Type Unspecified
C54868Medicare UPIN