Healthcare Provider Details

I. General information

NPI: 1265782247
Provider Name (Legal Business Name): IASMINA JIVANOV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 SANTA BARBARA BLVD STE 102
CAPE CORAL FL
33991-2038
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-1900
  • Fax: 239-424-1908
Mailing address:
  • Phone: 239-424-1900
  • Fax: 239-424-1908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME120026
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME120026
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number267293
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: