Provider Demographics
NPI:1720260441
Name:LAW, IVAN PE (MD)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:PE
Last Name:LAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX N
Mailing Address - Street 2:
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-0319
Mailing Address - Country:US
Mailing Address - Phone:360-642-3747
Mailing Address - Fax:360-642-3361
Practice Address - Street 1:176 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9137
Practice Address - Country:US
Practice Address - Phone:360-642-3747
Practice Address - Fax:360-642-3361
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00031977207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1233709Medicaid
OR041160Medicaid
WAG8808573Medicare PIN
WA1233709Medicaid
OR041160Medicaid