Healthcare Provider Details

I. General information

NPI: 1710172853
Provider Name (Legal Business Name): IVAN A DARENKOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 HAMBURG TPKE SUITE 103
WAYNE NJ
07470-2025
US

IV. Provider business mailing address

510 HAMBURG TPKE SUITE 103
WAYNE NJ
07470-2025
US

V. Phone/Fax

Practice location:
  • Phone: 845-341-0264
  • Fax: 845-343-0962
Mailing address:
  • Phone: 845-341-0264
  • Fax: 845-343-0962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA08165200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA08165200
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number25MA08165200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: