Provider Demographics
NPI:1285671628
Name:BOYDSTUN, IVY (MD)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:BOYDSTUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:1131 N 35TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-265-9344
Practice Address - Fax:954-986-5122
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1010072080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000070000Medicaid
NY450Z91OtherEMPIRE BC.BS
NY4638349OtherAETNA
NYF88632Medicare UPIN
NY4638349OtherAETNA