Provider Demographics
NPI:1780693630
Name:IVY, MICHAEL E (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:IVY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 GAYLORD FARM RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2899
Mailing Address - Country:US
Mailing Address - Phone:203-284-2800
Mailing Address - Fax:
Practice Address - Street 1:50 GAYLORD FARM RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2899
Practice Address - Country:US
Practice Address - Phone:203-284-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0352242086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001352244Medicaid