Provider Demographics
NPI:1427036581
Name:IVERSEN, MARTIN J (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:IVERSEN
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 1:1901 S UNION AVE
Mailing Address - Street 2:STE A223
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1702
Mailing Address - Country:US
Mailing Address - Phone:253-459-6570
Mailing Address - Fax:
Practice Address - Street 1:1901 S UNION AVE
Practice Address - Street 2:STE A223
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1702
Practice Address - Country:US
Practice Address - Phone:253-459-6570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-08
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5546IVOtherREGENCE
WA8906215OtherCVCP
WA8427163Medicaid
WAEXOtherKPS
WA246477OtherL&I
WAEXOtherKPS