Provider Demographics
NPI:1801854435
Name:JANDOVA, IVA (MD)
Entity type:Individual
Prefix:MRS
First Name:IVA
Middle Name:
Last Name:JANDOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IVA
Other - Middle Name:
Other - Last Name:PRAVDOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:61 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7841
Mailing Address - Country:US
Mailing Address - Phone:617-710-0379
Mailing Address - Fax:
Practice Address - Street 1:2100 DORCHESTER AVE
Practice Address - Street 2:STEWARD CARNEY HOSPITAL
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124
Practice Address - Country:US
Practice Address - Phone:617-506-4504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1610992084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0116513Medicaid
MAA31842Medicaid