Provider Demographics
NPI:1871506659
Name:SULTAN, IVAN (MPT)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:SULTAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 15TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3824
Mailing Address - Country:US
Mailing Address - Phone:503-468-2469
Mailing Address - Fax:503-338-7557
Practice Address - Street 1:2265 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3331
Practice Address - Country:US
Practice Address - Phone:503-338-4005
Practice Address - Fax:503-338-7557
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist