Healthcare Provider Details

I. General information

NPI: 1689769416
Provider Name (Legal Business Name): INGRID C IWANOW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 03/05/2021
Certification Date: 03/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 AMHERST ST STE 2B
WINCHESTER VA
22601-2841
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 100
WINCHESTER VA
22601-2896
US

V. Phone/Fax

Practice location:
  • Phone: 540-536-2790
  • Fax: 540-536-2791
Mailing address:
  • Phone: 540-536-5100
  • Fax: 540-536-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101231531
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: