Provider Demographics
NPI:1265682645
Name:MADSON, IVY TAT (OD, MS)
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:TAT
Last Name:MADSON
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:DR
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:TAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD, MS
Mailing Address - Street 1:100 M ST SE STE 675
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-3519
Mailing Address - Country:US
Mailing Address - Phone:800-485-9196
Mailing Address - Fax:
Practice Address - Street 1:100 M ST SE STE 675
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-3519
Practice Address - Country:US
Practice Address - Phone:800-485-9196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOP2000530152W00000X
UT7056618-8908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist