MEDICARE: ILIYAN STOYANOV IVANOV M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	60-220252	NY

General Provider Information

NPI Number	:	1518987510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILIYAN STOYANOV IVANOV M.D.

Provider Business Mailing Address
First Line	:	235 E 95TH ST APT 26C
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10128-0229
Country	:	US
Telephone Number	:	646-387-6080
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 GUSTAVE L LEVY PL # 1228
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10029-6500
Country	:	US
Telephone Number	:	212-659-8833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	07/08/2007

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