Provider Demographics
NPI:1457941999
Name:PIERRA, IVAN R (ATC)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:R
Last Name:PIERRA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MELANIE LN
Mailing Address - Street 2:
Mailing Address - City:WHIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07981-1637
Mailing Address - Country:US
Mailing Address - Phone:562-505-7598
Mailing Address - Fax:
Practice Address - Street 1:24 MELANIE LN
Practice Address - Street 2:
Practice Address - City:WHIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07981-1637
Practice Address - Country:US
Practice Address - Phone:562-505-7598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002776002083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty