Provider Demographics
NPI:1679013833
Name:IVANOV, SERGEY VLADIMIROVICH (DO)
Entity Type:Individual
Prefix:
First Name:SERGEY
Middle Name:VLADIMIROVICH
Last Name:IVANOV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RUSSELL AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE CHASSE
Mailing Address - State:LA
Mailing Address - Zip Code:70037-1006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:BELLE CHASSE
Practice Address - State:LA
Practice Address - Zip Code:70037-1006
Practice Address - Country:US
Practice Address - Phone:386-237-7156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02005547A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program