Provider Demographics
NPI:1568788602
Name:IVERSON, RICHARD BLAINE (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BLAINE
Last Name:IVERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10003 S CHIP CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2781
Mailing Address - Country:US
Mailing Address - Phone:801-350-4734
Mailing Address - Fax:
Practice Address - Street 1:1050 E SOUTH TEMPLE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1507
Practice Address - Country:US
Practice Address - Phone:801-350-4734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8199146-1204207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology