Provider Demographics
NPI:1992763411
Name:IVAN, THOMAS S (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:IVAN
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:T
Other - Middle Name:STEVEN
Other - Last Name:IVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:7111 E 21ST ST N STE A
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-1078
Mailing Address - Country:US
Mailing Address - Phone:316-684-2851
Mailing Address - Fax:316-683-5239
Practice Address - Street 1:7111 E 21ST ST N STE A
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1078
Practice Address - Country:US
Practice Address - Phone:316-684-2851
Practice Address - Fax:316-683-5239
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4082207Q00000X
KS05-50713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200076860AMedicaid
OKI22763Medicare UPIN
OKP00333174Medicare PIN
OK243622101Medicare PIN