Provider Demographics
NPI:1154346393
Name:SHVACHUK, IVAN (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:SHVACHUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 ERIE BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12305-1026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 NOTT ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-2425
Practice Address - Country:US
Practice Address - Phone:518-243-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240695207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10115093OtherCDPHP
NY000411953001OtherBSNENY
11568824OtherCAQH
NY4149461OtherMVP
NY070209000089OtherFIDELIS CARE
NY240SD1OtherBLUE CROSS
NY4149461OtherMVP
NYRB1117Medicare ID - Type Unspecified