Provider Demographics
NPI:1790223667
Name:ANCOR, IGOR
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:ANCOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 298
Mailing Address - Street 2:
Mailing Address - City:HOMERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31634-0298
Mailing Address - Country:US
Mailing Address - Phone:912-470-2273
Mailing Address - Fax:
Practice Address - Street 1:80 HUXFORD ST
Practice Address - Street 2:
Practice Address - City:HOMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:31634
Practice Address - Country:US
Practice Address - Phone:912-470-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA83426207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program