Basic Information
Provider Information
NPI: 1003004169
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: IVEY
FirstName: SUSAN
MiddleName: LEE
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 131 EMERALD DR
Address2:  
City: DANVILLE
State: CA
PostalCode: 945262426
CountryCode: US
TelephoneNumber: 9253628227
FaxNumber: 9253628228
Practice Location
Address1: 2140 SHATTUCK AVE
Address2: 10TH FLOOR, HEALTH RESEARCH FOR ACTION, UC-BERKELEY SPH
City: BERKELEY
State: CA
PostalCode: 947041210
CountryCode: US
TelephoneNumber: 5106431883
FaxNumber: 5106437976
Other Information
ProviderEnumerationDate: 10/12/2007
LastUpdateDate: 10/12/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XC43335CAY Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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