Healthcare Provider Details

I. General information

NPI: 1245428630
Provider Name (Legal Business Name): IVANKA A. VASSILEVA, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 W GORE BLVD SUITE B-10
LAWTON OK
73505-5977
US

IV. Provider business mailing address

4411 W GORE BLVD SUITE B-10
LAWTON OK
73505-5977
US

V. Phone/Fax

Practice location:
  • Phone: 580-354-9600
  • Fax: 580-354-9621
Mailing address:
  • Phone: 580-354-9600
  • Fax: 580-354-9621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22970
License Number StateOK

VIII. Authorized Official

Name: MS. IVANKA A. VASSILEVA
Title or Position: OWNER
Credential: M.D.
Phone: 580-354-9600