Provider Demographics
NPI: | 1528393063 |
---|---|
Name: | DY, IRENE A (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | IRENE |
Middle Name: | A |
Last Name: | DY |
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: | PO BOX 50095 |
Mailing Address - Street 2: | |
Mailing Address - City: | SEATTLE |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98145-5095 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 39000 BOB HOPE DR |
Practice Address - Street 2: | |
Practice Address - City: | RANCHO MIRAGE |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92270-3221 |
Practice Address - Country: | US |
Practice Address - Phone: | 760-346-7655 |
Practice Address - Fax: | 760-346-3037 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2009-10-15 |
Last Update Date: | 2023-05-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | MD61059558 | 207RH0003X |
CA | A120038 | 207RH0003X |
IL | 036129802 | 207RX0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RX0202X | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 036129802 | Medicaid |