Provider Demographics
NPI:1699742312
Name:FOMITCHEV, IVAN (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:FOMITCHEV
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 1:8711 WALES RESERVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-3371
Mailing Address - Country:US
Mailing Address - Phone:563-564-1283
Mailing Address - Fax:
Practice Address - Street 1:8711 WALES RESERVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78255-3371
Practice Address - Country:US
Practice Address - Phone:563-564-1283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34875208VP0000X, 207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0274506Medicaid
WI34312600Medicaid
IA0274506Medicaid
IA0274506Medicaid