Provider Demographics
NPI:1720194483
Name:SNOWDEN, IVAN T (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:T
Last Name:SNOWDEN
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 1:834 N SEMINARY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2852
Mailing Address - Country:US
Mailing Address - Phone:309-343-2273
Mailing Address - Fax:
Practice Address - Street 1:1005 HEALTH CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938
Practice Address - Country:US
Practice Address - Phone:217-258-4006
Practice Address - Fax:217-258-4120
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-058846208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics