Healthcare Provider Details

I. General information

NPI: 1649488255
Provider Name (Legal Business Name): IVAN JOHN CHRISTOV NICOLOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BIA RTE 125
PINE HILL NM
87357
US

IV. Provider business mailing address

BIA RTE 125 310
PINE HILL NM
87357
US

V. Phone/Fax

Practice location:
  • Phone: 505-775-3271
  • Fax: 505-775-3930
Mailing address:
  • Phone: 505-775-3271
  • Fax: 505-775-3930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberMD20060115
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: