Healthcare Provider Details

I. General information

NPI: 1003004169
Provider Name (Legal Business Name): SUSAN LEE IVEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 SHATTUCK AVE 10TH FLOOR, HEALTH RESEARCH FOR ACTION, UC-BERKELEY SPH
BERKELEY CA
94704-1210
US

IV. Provider business mailing address

131 EMERALD DR
DANVILLE CA
94526-2426
US

V. Phone/Fax

Practice location:
  • Phone: 510-643-1883
  • Fax: 510-643-7976
Mailing address:
  • Phone: 925-362-8227
  • Fax: 925-362-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC43335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: