Provider Demographics
NPI:1497747885
Name:IVERSON, CHERYL J (DO)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:J
Last Name:IVERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 W FOND DU LAC ST
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:WI
Mailing Address - Zip Code:54971-9286
Mailing Address - Country:US
Mailing Address - Phone:920-748-7000
Mailing Address - Fax:920-748-7236
Practice Address - Street 1:1080 W FOND DU LAC ST
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:WI
Practice Address - Zip Code:54971-9286
Practice Address - Country:US
Practice Address - Phone:920-748-7000
Practice Address - Fax:920-748-7236
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46185-021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43511200Medicaid
WI43511200Medicaid
WI008800416Medicare PIN