Provider Demographics
NPI:1114017290
Name:IVERSEN, ROBERT H (DC, CCSP)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:H
Last Name:IVERSEN
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 OLD MEADOW RD
Mailing Address - Street 2:STE 600
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-4311
Mailing Address - Country:US
Mailing Address - Phone:703-506-0213
Mailing Address - Fax:
Practice Address - Street 1:2702 N 44TH ST
Practice Address - Street 2:101A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-1583
Practice Address - Country:US
Practice Address - Phone:480-990-9095
Practice Address - Fax:480-941-1233
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4858111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0242900OtherBCBS
AZAW2551OtherHEALTHNET
AZ162173Medicaid
AZ2455228OtherAETNA
AZZWDCFB01Medicare PIN
AZ2455228OtherAETNA