Provider Demographics
NPI:1245428630
Name:IVANKA A. VASSILEVA, M.D., P.C.
Entity type:Organization
Organization Name:IVANKA A. VASSILEVA, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:IVANKA
Authorized Official - Middle Name:A
Authorized Official - Last Name:VASSILEVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-354-9600
Mailing Address - Street 1:4411 W GORE BLVD
Mailing Address - Street 2:SUITE B-10
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5977
Mailing Address - Country:US
Mailing Address - Phone:580-354-9600
Mailing Address - Fax:580-354-9621
Practice Address - Street 1:4411 W GORE BLVD
Practice Address - Street 2:SUITE B-10
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5977
Practice Address - Country:US
Practice Address - Phone:580-354-9600
Practice Address - Fax:580-354-9621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK300522163Medicare PIN