Provider Demographics
NPI:1992190433
Name:IVANOVIC, AMY (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:IVANOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 WATERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2066
Mailing Address - Country:US
Mailing Address - Phone:860-678-3400
Mailing Address - Fax:
Practice Address - Street 1:103 NEWTOWN RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4195
Practice Address - Country:US
Practice Address - Phone:203-730-8789
Practice Address - Fax:703-717-4055
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10505900207V00000X
VA0101268763207V00000X
390200000X
CT69411207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program