Healthcare Provider Details

I. General information

NPI: 1295729929
Provider Name (Legal Business Name): IVANKA A VASSILEVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 W GORE BLVD STE B10
LAWTON OK
73505-5977
US

IV. Provider business mailing address

4411 W GORE BLVD STE B10
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:
Title or Position:
Credential:
Phone: