Provider Demographics
NPI:1578945416
Name:IVANOV, ZHANNA (MD, MS)
Entity Type:Individual
Prefix:
First Name:ZHANNA
Middle Name:
Last Name:IVANOV
Suffix:
Gender:F
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 GEORGE ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1031
Mailing Address - Country:US
Mailing Address - Phone:908-202-0460
Mailing Address - Fax:
Practice Address - Street 1:110 REHILL AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876
Practice Address - Country:US
Practice Address - Phone:908-685-2899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-28
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10337500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty