Provider Demographics
NPI:1568403269
Name:MAILLARD, IVAN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:PATRICK
Last Name:MAILLARD
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 1:3400 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4238
Mailing Address - Country:US
Mailing Address - Phone:215-615-0063
Mailing Address - Fax:215-349-8144
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-615-0063
Practice Address - Fax:215-349-8144
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423465207R00000X, 207RH0000X
MI4301090943207RX0202X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013530260002Medicaid
MII37548Medicare UPIN
PA1013530260002Medicaid
I37548Medicare UPIN