Provider Demographics
NPI:1548563430
Name:IVANOV, PHILIP
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:IVANOV
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 1:180 ALT 19
Mailing Address - Street 2:SUITE B
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-5308
Mailing Address - Country:US
Mailing Address - Phone:727-785-8737
Mailing Address - Fax:727-786-8546
Practice Address - Street 1:180 ALT 19
Practice Address - Street 2:SUITE B
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-5308
Practice Address - Country:US
Practice Address - Phone:727-785-8737
Practice Address - Fax:727-786-8546
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist