Individual
DR. ILYA IVANOV
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
100 CENTURY PKWY STE 350, MOUNT LAUREL, NJ 08054-1149
(856) 482-9000
(856) 482-1159
Mailing address
100 CENTURY PKWY STE 350, MOUNT LAUREL, NJ 08054-1149
(856) 482-9000
(856) 482-1159
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
025MB8329500
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0211699
—
NJ
01
—
P00772213
RAILROAD MEDICARE
NJ
Enumeration date
09/05/2007
Last updated
03/14/2024
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