Provider Demographics
NPI:1629000377
Name:IVAN G PROANO MD PLLC
Entity Type:Organization
Organization Name:IVAN G PROANO MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:PROANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-342-6176
Mailing Address - Street 1:15 BRONSON ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-1004
Mailing Address - Country:US
Mailing Address - Phone:315-342-6176
Mailing Address - Fax:315-342-3120
Practice Address - Street 1:15 BRONSON ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-1004
Practice Address - Country:US
Practice Address - Phone:315-342-6176
Practice Address - Fax:315-342-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00000000207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02258024Medicaid
NY4487420001Medicare NSC
NY02258024Medicaid