Provider Demographics
NPI:1356309728
Name:IVERSON, DONALD J (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:J
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 1:2828 ONEIL LANE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-4870
Mailing Address - Country:US
Mailing Address - Phone:707-443-9385
Mailing Address - Fax:707-443-0258
Practice Address - Street 1:2828 ONEIL LANE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4870
Practice Address - Country:US
Practice Address - Phone:707-443-9385
Practice Address - Fax:707-443-0258
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG608002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G608000Medicaid
WA0165084OtherDEPF OF LABOR & INDUSTRIE
130004938OtherRAILROAD MEDICARE
00G608000Medicare ID - Type Unspecified
WA0165084OtherDEPF OF LABOR & INDUSTRIE