Healthcare Provider Details

I. General information

NPI: 1982883963
Provider Name (Legal Business Name): ZLATIN S IVANOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 BROADWAY DEPARTMENT OF PSYCHIATRY WOODHULL MEDICAL & MENTAL HEALTH CENTER
BROOKLYN NY
11206
US

IV. Provider business mailing address

760 BROADWAY DEPARTMENT OF MANAGED CARE ROOM 2B230 WOODHULL MEDICAL & MENTAL HEALTH CENTER
BROOKLYN NY
11206
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-8000
  • Fax:
Mailing address:
  • Phone: 718-963-8000
  • Fax: 718-630-3122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number242883
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: