Provider Demographics
NPI:1699066373
Name:IVANOVA, KATERYNA (DO)
Entity type:Individual
Prefix:DR
First Name:KATERYNA
Middle Name:
Last Name:IVANOVA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-2207
Mailing Address - Country:US
Mailing Address - Phone:888-285-2269
Mailing Address - Fax:512-838-4264
Practice Address - Street 1:474 N YELLOW SPRINGS STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2938
Practice Address - Country:US
Practice Address - Phone:937-399-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN636252084P0800X
TXQ38922084P0800X
WI19-3212084P0800X
WAOP608514952084P0800X
ORDO1871582084P0800X
MO201901333982084P0800X
MS263232084P0800X
OH34.0111562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry