Provider Demographics
NPI:1497725857
Name:IVANOFF, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:IVANOFF
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 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:
Practice Address - Street 1:10505 E 91ST ST
Practice Address - Street 2:SUITE 208
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5801
Practice Address - Country:US
Practice Address - Phone:918-494-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19125207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100023590AMedicaid
OK300522262OtherMEDICARE GROUP PIN
OKB34261Medicare UPIN
OK100023590AMedicaid