Provider Demographics
NPI:1619985645
Name:BOLIVAR, IVAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:A
Last Name:BOLIVAR
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 1:9915 BRENTFORD CT
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5310
Mailing Address - Country:US
Mailing Address - Phone:407-304-9331
Mailing Address - Fax:321-207-0175
Practice Address - Street 1:5703 RED BUG LAKE RD
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-4969
Practice Address - Country:US
Practice Address - Phone:407-849-7500
Practice Address - Fax:321-207-0175
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH00783Medicare UPIN
FL57893ZMedicare ID - Type Unspecified