Individual
DR. MICHAEL MSTISLAVOVICH IVANITSKY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
940 E 5TH ST, COQUILLE, OR 97423-1699
(541) 396-3111
(541) 396-8135
Mailing address
940 E 5TH ST, COQUILLE, OR 97423-1666
(541) 396-3111
(541) 396-8135
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
MD22589
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
288121
—
OR
Enumeration date
07/21/2006
Last updated
09/04/2020
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