Provider Demographics
NPI:1316078470
Name:IVASCU, FELICIA
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:
Last Name:IVASCU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3535 W 13 MILE RD
Mailing Address - Street 2:607
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073
Mailing Address - Country:US
Mailing Address - Phone:248-288-1130
Mailing Address - Fax:248-288-5931
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:607
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-288-1130
Practice Address - Fax:248-288-5931
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIFI0760312086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI061807327OtherTAX IDENTIFICATION