Healthcare Provider Details

I. General information

NPI: 1871054999
Provider Name (Legal Business Name): IVAN KRASNOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 BROADWAY STE 100
SANTA MONICA CA
90401-2389
US

IV. Provider business mailing address

127 BROADWAY STE 100
SANTA MONICA CA
90401-2389
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-8420
  • Fax:
Mailing address:
  • Phone: 310-340-6616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA198433
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD479185
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: