Healthcare Provider Details

I. General information

NPI: 1124656822
Provider Name (Legal Business Name): IVAN FEDORIV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MEDICAL PKWY # 207
ANNAPOLIS MD
21401-3773
US

IV. Provider business mailing address

2001 MEDICAL PKWY
ANNAPOLIS MD
21401-3773
US

V. Phone/Fax

Practice location:
  • Phone: 443-336-3031
  • Fax:
Mailing address:
  • Phone: 443-336-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD0105442
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: