Basic Information
| Provider Information | |||||||||
| NPI: | 1598095929 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | IVANUKOFF | ||||||||
| FirstName: | VICTORIA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 SOUTHCREST DR | ||||||||
| Address2: | STE 250 | ||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709969945 | ||||||||
| FaxNumber: | 8442699596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1532 LONE OAK RD STE 405 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704414300 | ||||||||
| FaxNumber: | 2704414370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2010 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 076643 | GA | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 04487 | KY | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.