Provider Demographics
NPI:1891783130
Name:IVANOV, SVETLIN S (MD)
Entity Type:Individual
Prefix:
First Name:SVETLIN
Middle Name:S
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 1:120 MINEOLA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4064
Mailing Address - Country:US
Mailing Address - Phone:516-663-3010
Mailing Address - Fax:516-663-3026
Practice Address - Street 1:120 MINEOLA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4064
Practice Address - Country:US
Practice Address - Phone:516-663-3010
Practice Address - Fax:516-663-3026
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235678 1207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02762783Medicaid
I33376Medicare UPIN
NY02762783Medicaid