MEDICARE: IVONNE MCLEAN 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	207Q00000X	Family Medicine Physician	260241	MA
2	207Q00000X	Family Medicine Physician	290743	NY

General Provider Information

NPI Number	:	1366861460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVONNE MCLEAN M.D.

Provider Business Mailing Address
First Line	:	1894 WALTON AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10453-6018
Country	:	US
Telephone Number	:	718-583-3060
Fax Number	:	718-583-3360

Provider Business Practice Location Address
First Line	:	2006 MADISON AVE FL 1
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-1217
Country	:	US
Telephone Number	:	415-722-7785
Fax Number	:

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

Provider Enumeration Date	:	04/16/2014
Last Update Date	:	07/21/2022

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