Provider Demographics
NPI:1790825222
Name:IVANOV, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:IVANOV
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 1:178 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-4703
Mailing Address - Country:US
Mailing Address - Phone:718-975-7690
Mailing Address - Fax:718-975-7692
Practice Address - Street 1:115 BRIGHTWATER CT
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7652
Practice Address - Country:US
Practice Address - Phone:718-975-7690
Practice Address - Fax:718-975-7690
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2052062084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01842337Medicaid
G49918Medicare UPIN
52M921Medicare ID - Type Unspecified