Provider Demographics
NPI:1487609285
Name:IVANOV, OLGA (MD)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:IVANOV
Suffix:
Gender:F
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 538600
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32853-8600
Mailing Address - Country:US
Mailing Address - Phone:407-303-4760
Mailing Address - Fax:407-303-4546
Practice Address - Street 1:380 CELEBRATION PLACE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747
Practice Address - Country:US
Practice Address - Phone:407-303-4760
Practice Address - Fax:407-303-4546
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114714208600000X
FLME110167208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery