MEDICARE: JOHN G IVANOFF M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician	19125	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	300522262	OTHER	OK	MEDICARE GROUP PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497725857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN G IVANOFF M.D.

Provider Business Mailing Address
First Line	:	6600 S YALE AVE
Second Line	:	SUITE 1400
City	:	TULSA
State	:	OK
Zip	:	74136-3347
Country	:	US
Telephone Number	:	918-488-6001
Fax Number	:

Provider Business Practice Location Address
First Line	:	10505 E 91ST ST
Second Line	:	SUITE 208
City	:	TULSA
State	:	OK
Zip	:	74133-5801
Country	:	US
Telephone Number	:	918-494-8500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	06/13/2019

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Directions to “ JOHN G IVANOFF M.D.” Practice Location

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