Provider Demographics
NPI:1689769416
Name:IWANOW, INGRID C (MD)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:C
Last Name:IWANOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:220 CAMPUS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2896
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:540-536-0235
Practice Address - Street 1:1870 AMHERST ST STE 2B
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2841
Practice Address - Country:US
Practice Address - Phone:540-536-2790
Practice Address - Fax:540-536-2791
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231531207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00417900OtherRR MEDICARE
VA1689769416Medicaid
VA1689769416Medicaid
VAP00417900OtherRR MEDICARE