Provider Demographics
NPI:1912940107
Name:FERNANDEZ-MADRID, IVAN J (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:J
Last Name:FERNANDEZ-MADRID
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IVAN
Other - Middle Name:
Other - Last Name:MADRID
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:205 EAST 16TH STREET
Mailing Address - Street 2:SUITE M1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003
Mailing Address - Country:US
Mailing Address - Phone:212-254-0946
Mailing Address - Fax:212-254-0956
Practice Address - Street 1:380 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-5615
Practice Address - Country:US
Practice Address - Phone:212-598-6655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217407207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY857G9OtherEMPIRE BLUE CROSS BLUE SHIELD
NYP2384505OtherOXFORD
NY217407OtherMEDICAL LICENSE
NY390091POtherHIP PROVIDER PRIS#
NY384G7ZT3V1Medicare PIN
NY857G9OtherEMPIRE BLUE CROSS BLUE SHIELD