Basic Information
| Provider Information | |||||||||
| NPI: | 1316398506 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ZADOUNAEV | ||||||||
| FirstName: | IVAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1260 2ND AVE SE | ||||||||
| Address2: | CEDAR RAPIDS MEDICAL EDUCATION FOUNDATION | ||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524034002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192972300 | ||||||||
| FaxNumber: | 3192972280 | ||||||||
| Practice Location | |||||||||
| Address1: | 59 PAGE HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035703531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037522200 | ||||||||
| FaxNumber: | 6033265831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2016 | ||||||||
| LastUpdateDate: | 05/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R-10727 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 19489 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 19489 | 01 | NH | NH LICENSE | OTHER |