Provider Demographics
NPI:1437311222
Name:IVANOV, OLEG (MD)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:IVANOV
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 1:1230 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2704
Mailing Address - Country:US
Mailing Address - Phone:307-266-3174
Mailing Address - Fax:307-266-3177
Practice Address - Street 1:1230 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2704
Practice Address - Country:US
Practice Address - Phone:307-266-3174
Practice Address - Fax:307-266-3177
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8672A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease