Provider Demographics
NPI:1629461348
Name:IVASHKOV, OLGA (LAC)
Entity Type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:IVASHKOV
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7476
Mailing Address - Country:US
Mailing Address - Phone:201-725-1182
Mailing Address - Fax:
Practice Address - Street 1:6 PHEASANT RUN
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-7476
Practice Address - Country:US
Practice Address - Phone:201-725-1182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004126171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist