Provider Demographics
NPI:1073573408
Name:IVERSON, DUANE R
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:R
Last Name:IVERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 SW MORRISON ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1945
Mailing Address - Country:US
Mailing Address - Phone:503-242-9850
Mailing Address - Fax:503-279-8157
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:SUITE 505
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3033
Practice Address - Country:US
Practice Address - Phone:503-226-4091
Practice Address - Fax:503-226-3539
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09470207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR093641Medicaid
C92943Medicare UPIN
OROOFBKQDMedicare ID - Type Unspecified