Provider Demographics
NPI:1821585886
Name:IVANOV, STANISLAV ASENOV (MD)
Entity type:Individual
Prefix:
First Name:STANISLAV
Middle Name:ASENOV
Last Name:IVANOV
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 1:11952 SW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-7807
Mailing Address - Country:US
Mailing Address - Phone:786-487-2544
Mailing Address - Fax:
Practice Address - Street 1:12235 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-4119
Practice Address - Country:US
Practice Address - Phone:954-265-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME150551207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program