Healthcare Provider Details

I. General information

NPI: 1699066373
Provider Name (Legal Business Name): KATERYNA IVANOVA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 N YELLOW SPRINGS STREET
SPRINGFIELD OH
45504-2938
US

IV. Provider business mailing address

807 WEST AVE
AUSTIN TX
78701-2207
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-9500
  • Fax:
Mailing address:
  • Phone: 888-285-2269
  • Fax: 512-838-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number63625
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberQ3892
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number19-321
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOP60851495
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO187158
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20190133398
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number26323
License Number StateMS
# 8
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34.011156
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: