Active NPI
Andrey Ivanov, DDS
- General Practice Dentistry
- Brooklyn, NY
National Provider Identifier
1578883419
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 049734
- Practice address
- 575 Fulton St
2ND Floor
Brooklyn, NY 11201-5309 - Phone
- (718) 596-5378
- NPI assigned
- Jun 2, 2010
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 049734 | NY | Primary |
Addresses
Primary practice location
575 Fulton St
2ND Floor
Brooklyn, NY 11201-5309
Mailing address
803 Plaza Dr
Woodbridge, NJ 07095-1114
Phone (732) 636-7624
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 049734 | NY | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1275436800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1275436800000",
"number": "1578883419",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "803 PLAZA DR",
"city": "WOODBRIDGE",
"state": "NJ",
"postal_code": "070951114",
"telephone_number": "732-636-7624"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "575 FULTON ST",
"address_2": "2ND FLOOR",
"city": "BROOKLYN",
"state": "NY",
"postal_code": "112015309",
"telephone_number": "718-596-5378"
}
],
"practiceLocations": [],
"basic": {
"last_name": "IVANOV",
"first_name": "ANDREY",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2010-06-02",
"last_updated": "2010-06-02",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "NY",
"license": "049734",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Brooklyn, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.