Provider Demographics
NPI:1871668293
Name:IVY, CHARISE LEANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARISE
Middle Name:LEANNE
Last Name:IVY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARISE
Other - Middle Name:LEANNE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1237
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91025-4237
Mailing Address - Country:US
Mailing Address - Phone:626-808-5352
Mailing Address - Fax:626-797-3864
Practice Address - Street 1:1500 E CHEVY CHASE DR STE 401
Practice Address - Street 2:GLENDALE ADVENTIST MEDICAL CENTER SPINE INSTITUTE
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4153
Practice Address - Country:US
Practice Address - Phone:818-863-4451
Practice Address - Fax:818-863-4984
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA242320208100000X
CAA86275208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI12378Medicare UPIN
CAWA86275AMedicare ID - Type Unspecified