Provider Demographics
NPI:1255325809
Name:LIN, IVY (OD)
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:
Last Name:LIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11245 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90606-3111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11245 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90606-3111
Practice Address - Country:US
Practice Address - Phone:562-692-1208
Practice Address - Fax:562-695-6386
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12327T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0123270Medicaid
CAU96997Medicare UPIN
CASD0123270Medicaid