Healthcare Provider Details

I. General information

NPI: 1356873657
Provider Name (Legal Business Name): ALEXANDER ANATOLEVICH IVANOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR STE 200
GASTONIA NC
28054-2178
US

IV. Provider business mailing address

2555 COURT DR STE 200
GASTONIA NC
28054-2178
US

V. Phone/Fax

Practice location:
  • Phone: 704-834-3278
  • Fax:
Mailing address:
  • Phone: 704-834-3278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number262249
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number262249
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: