Provider Demographics
NPI:1669560280
Name:IVANOV, MAXIM I (DC)
Entity type:Individual
Prefix:
First Name:MAXIM
Middle Name:I
Last Name:IVANOV
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-3431
Mailing Address - Country:US
Mailing Address - Phone:574-533-7363
Mailing Address - Fax:
Practice Address - Street 1:401 E MADISON ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3431
Practice Address - Country:US
Practice Address - Phone:574-533-7363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002243A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor