Provider Demographics
NPI:1275502007
Name:NAYERI, JUDITH LYNNE (DO)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:LYNNE
Last Name:NAYERI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:LYNNE
Other - Last Name:MCIVOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-2974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:1701 22ND ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1443
Practice Address - Country:US
Practice Address - Phone:515-440-6622
Practice Address - Fax:515-440-6698
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02946207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46814Medicare UPIN