Provider Demographics
NPI:1942201868
Name:FASKE, IVY (MD)
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:
Last Name:FASKE
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 1:11211 PROSPERITY FARMS RD STE A102
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-3479
Mailing Address - Country:US
Mailing Address - Phone:561-626-4677
Mailing Address - Fax:561-293-7060
Practice Address - Street 1:3365 BURNS RD
Practice Address - Street 2:SUITE 206
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4303
Practice Address - Country:US
Practice Address - Phone:561-626-4677
Practice Address - Fax:561-626-6995
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 49705208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04337OtherBLUE CROSS BLUE SHIELD