=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528517331
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROMAN IVANKIV
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2016
-----------------------------------------------------
Last Update Date | 03/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 TREE BLVD STE 112
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-5720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-826-1900
-----------------------------------------------------
Fax | 904-826-1920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1740 TREE BLVD STE 112
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-5720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-826-1900
-----------------------------------------------------
Fax | 904-826-1920
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | 338
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | PO4215
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------