Provider Demographics
NPI:1750644001
Name:SOFJAN, IWAN PRAYOGA (MD)
Entity Type:Individual
Prefix:
First Name:IWAN
Middle Name:PRAYOGA
Last Name:SOFJAN
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 1:3471 5TH AVE
Mailing Address - Street 2:SUITE 910
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-3215
Mailing Address - Country:US
Mailing Address - Phone:412-692-4503
Mailing Address - Fax:412-692-4515
Practice Address - Street 1:3471 5TH AVE
Practice Address - Street 2:SUITE 910
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3215
Practice Address - Country:US
Practice Address - Phone:412-692-4503
Practice Address - Fax:412-692-4515
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287280207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology