Provider Demographics
NPI:1891796165
Name:ISSA, IVY C (MD)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:C
Last Name:ISSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:C
Other - Last Name:PANDIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2080 COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-1649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2030 MOUNTAIN VIEW AVE STE 300
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3181
Practice Address - Country:US
Practice Address - Phone:720-652-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0068779207R00000X, 207RH0002X, 207RG0300X
CAC53735207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89130RFMedicaid
NC136W5OtherBCBS
380001702OtherRAILROAD MEDICARE B
G77911Medicare UPIN
2293941Medicare PIN