Provider Demographics
NPI:1437197928
Name:IVANSON, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:IVANSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANDREY
Other - Middle Name:
Other - Last Name:IVANUSHKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4817 BEDFORD AVE
Mailing Address - Street 2:3A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2783
Mailing Address - Country:US
Mailing Address - Phone:646-541-9779
Mailing Address - Fax:
Practice Address - Street 1:726 AVENUE Z
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-6238
Practice Address - Country:US
Practice Address - Phone:718-872-7373
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2091342084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01936034Medicaid
NY03484Medicare ID - Type UnspecifiedGHI MEDICARE
NY01936034Medicaid
NY17B731Medicare ID - Type UnspecifiedEMPIRE MEDICARE