MEDICARE: DR. IVY ANN LEE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	A111232	CA
2	207N00000X	Dermatology Physician	MD036840	DC

General Provider Information

NPI Number	:	1699947317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVY ANN LEE M.D.

Provider Business Mailing Address
First Line	:	960 E. GREEN STREET
Second Line	:	SUITE #330
City	:	PASADENA
State	:	CA
Zip	:	91106
Country	:	US
Telephone Number	:	626-449-4207
Fax Number	:	626-449-0925

Provider Business Practice Location Address
First Line	:	960 E. GREEN STREET
Second Line	:	SUITE #330
City	:	PASADENA
State	:	CA
Zip	:	91106
Country	:	US
Telephone Number	:	626-449-4207
Fax Number	:	626-449-0925

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2008
Last Update Date	:	05/16/2012

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