Provider Demographics
NPI:1215111042
Name:JOSEPH R. IVAN, MD, LLC
Entity type:Organization
Organization Name:JOSEPH R. IVAN, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:IVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-271-1771
Mailing Address - Street 1:1982 WASHINGTON VALLEY RD
Mailing Address - Street 2:PO BOX 309
Mailing Address - City:MARTINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08836-2043
Mailing Address - Country:US
Mailing Address - Phone:732-271-1771
Mailing Address - Fax:732-271-9477
Practice Address - Street 1:110 REHILL AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2519
Practice Address - Country:US
Practice Address - Phone:908-429-5817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05501700207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ041633OtherMEDICARE GROUP
NJ136194PCMOtherMEDICARE INDIVIDUAL
NJF65318Medicare UPIN