Provider Demographics
NPI:1306985387
Name:IVARSSON, BENGT (MD)
Entity type:Individual
Prefix:DR
First Name:BENGT
Middle Name:
Last Name:IVARSSON
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:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:1259 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6372
Practice Address - Country:US
Practice Address - Phone:610-402-9400
Practice Address - Fax:610-402-9420
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059004L2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001600222Medicaid
PA001600222Medicaid
076484Medicare PIN