Provider Demographics
NPI:1336186428
Name:IVEY, DONNA L (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:IVEY
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 8549
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0549
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:817-563-3699
Practice Address - Street 1:215 BJ LANE
Practice Address - Street 2:
Practice Address - City:POOLVILLE
Practice Address - State:TX
Practice Address - Zip Code:76487
Practice Address - Country:US
Practice Address - Phone:817-596-4951
Practice Address - Fax:817-563-3699
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8194207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00T90DOtherBCBS
TX139483515Medicaid
TXTIN PLUS 005OtherTRICARE
TXTIN PLUS 015OtherTRICARE
TXTIN PLUS 015OtherTRICARE
TX00T90DOtherBCBS
TX00T90DMedicare PIN
TX930074677Medicare PIN
TX8L4360Medicare Oscar/Certification