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General NPI Number Information
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NPI Number | 1790026011
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Entity Type | Individual
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Provider Name | YURIY OLEGOVICH IVANOV DO
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Gender | Male
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Dates
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Enumeration Date | 03/12/2013
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Last Update Date | 01/10/2025
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Provider Practice Location Address
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Address Line | 125 PATERSON ST
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City | NEW BRUNSWICK
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State | NJ
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Zip | 08901-1962
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Country | US
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Telephone | 732-235-7661
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Fax | 732-235-7246
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Provider Business Mailing Address
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Address Line | 1554 NORTHERN BLVD FL 4
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City | MANHASSET
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State | NY
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Zip | 11030-3053
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Country | US
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Telephone | 516-321-6410
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 276396
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | 1790026011
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License Number State | NJ
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