Healthcare Provider Details

I. General information

NPI: 1528517331
Provider Name (Legal Business Name): ROMAN IVANKIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 03/28/2021
Certification Date: 03/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 TREE BLVD STE 112
ST AUGUSTINE FL
32084-5720
US

IV. Provider business mailing address

1740 TREE BLVD STE 112
ST AUGUSTINE FL
32084-5720
US

V. Phone/Fax

Practice location:
  • Phone: 904-826-1900
  • Fax: 904-826-1920
Mailing address:
  • Phone: 904-826-1900
  • Fax: 904-826-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number338
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO4215
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: