Provider Demographics
NPI:1790705721
Name:CORONADO, IVAN (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:CORONADO
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 1:19083 TWO RIVER LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-6226
Mailing Address - Country:US
Mailing Address - Phone:561-470-5976
Mailing Address - Fax:
Practice Address - Street 1:16244 MILITARY TRL
Practice Address - Street 2:SUITE 560
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6534
Practice Address - Country:US
Practice Address - Phone:561-495-7787
Practice Address - Fax:561-495-1164
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073217207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG02554Medicare UPIN
FL49146ZMedicare ID - Type Unspecified