Provider Demographics
NPI:1003878349
Name:IVERSON, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:IVERSON
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 1:81 RIVER ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MONTPELIER
Mailing Address - State:VT
Mailing Address - Zip Code:05602-3792
Mailing Address - Country:US
Mailing Address - Phone:802-229-9554
Mailing Address - Fax:802-229-5906
Practice Address - Street 1:81 RIVER ST
Practice Address - Street 2:SUITE 204
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-3792
Practice Address - Country:US
Practice Address - Phone:802-229-9554
Practice Address - Fax:802-229-5906
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0007517207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009051Medicaid
VTY400338400Medicare PIN
VTVT9051Medicare PIN
VTB85807Medicare UPIN