Provider Demographics
NPI:1437390390
Name:IVANCSITS, DOUGLAS PETER (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:PETER
Last Name:IVANCSITS
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 1:5416 TYBEE ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-3307
Mailing Address - Country:US
Mailing Address - Phone:813-928-7954
Mailing Address - Fax:
Practice Address - Street 1:2330 UTAH AVE STE 200
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4817
Practice Address - Country:US
Practice Address - Phone:424-290-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1103792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012100700Medicaid
FLID925ZMedicare PIN
FL012100700Medicaid
FLID925XMedicare PIN