Provider Demographics
NPI:1457337867
Name:IVANOVIC, KAROLYN M (MD)
Entity Type:Individual
Prefix:
First Name:KAROLYN
Middle Name:M
Last Name:IVANOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KAROLYN
Other - Middle Name:M
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7595 ANAGRAM DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7399
Mailing Address - Country:US
Mailing Address - Phone:612-573-2200
Mailing Address - Fax:612-573-2274
Practice Address - Street 1:7595 ANAGRAM DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7399
Practice Address - Country:US
Practice Address - Phone:612-573-2200
Practice Address - Fax:612-573-2274
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI528082085R0202X
MN478842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1457337867Medicaid
MN300003711Medicare PIN
MN654428200Medicaid
WI35179000Medicaid
MN300005023Medicare PIN
MNI34599Medicare UPIN