Provider Demographics
NPI:1639234313
Name:IVANOV, MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:IVANOV
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E 44TH ST APT 19K
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-4453
Mailing Address - Country:US
Mailing Address - Phone:212-602-1722
Mailing Address - Fax:
Practice Address - Street 1:321 E 48TH ST
Practice Address - Street 2:1-E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-1749
Practice Address - Country:US
Practice Address - Phone:212-602-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020355103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5926OtherBIS
NY03809318Medicaid
NYJ400171490Medicare PIN