Healthcare Provider Details

I. General information

NPI: 1497725857
Provider Name (Legal Business Name): JOHN G IVANOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10505 E 91ST ST SUITE 208
TULSA OK
74133-5801
US

IV. Provider business mailing address

6600 S YALE AVE SUITE 1400
TULSA OK
74136-3347
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-8500
  • Fax:
Mailing address:
  • Phone: 918-488-6001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number19125
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: