Provider Demographics
NPI:1659488716
Name:IVY, LINDA MARIA (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIA
Last Name:IVY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 E BASSE RD STE 107
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-8409
Mailing Address - Country:US
Mailing Address - Phone:210-223-9617
Mailing Address - Fax:210-472-2669
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-539-9582
Practice Address - Fax:210-539-2075
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9865207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX389776YLLWOtherMEDICARE
TXP01627486OtherRR MEDICARE
TX8EW013OtherBCBS
TX389776YLLWMedicare PIN
TX8L11083Medicare PIN