Provider Demographics
NPI:1992785422
Name:IVANOV, ILKO V (MD)
Entity type:Individual
Prefix:DR
First Name:ILKO
Middle Name:V
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 1:5777 E MAYO BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4502
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:5777 E MAYO BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29630208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86080015085259A995OtherTRIWEST
AZP00254553OtherRAILROAD MEDICARE
AZ616998Medicaid
AZ616998Medicaid
AZZ101526Medicare PIN