Provider Demographics
NPI:1871723890
Name:IVANOV, PHILIP (DC)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:IVANOV
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6935 OLD CANTON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1284
Mailing Address - Country:US
Mailing Address - Phone:601-956-6050
Mailing Address - Fax:601-952-0738
Practice Address - Street 1:6935 OLD CANTON RD
Practice Address - Street 2:SUITE A
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1284
Practice Address - Country:US
Practice Address - Phone:601-956-6050
Practice Address - Fax:601-952-0738
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1148111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor