Provider Demographics
NPI:1881977171
Name:VIVANCO, ALIM
Entity type:Individual
Prefix:MISS
First Name:ALIM
Middle Name:
Last Name:VIVANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 HIBISCUS WAY
Mailing Address - Street 2:APT 312
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2393
Mailing Address - Country:US
Mailing Address - Phone:937-830-0114
Mailing Address - Fax:
Practice Address - Street 1:2641 HIBISCUS WAY
Practice Address - Street 2:APT 312
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2393
Practice Address - Country:US
Practice Address - Phone:937-830-0114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH23558185207Q00000X, 207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine