Provider Demographics
NPI:1619085354
Name:VINCENT M IVERS
Entity Type:Organization
Organization Name:VINCENT M IVERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:IVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-227-7070
Mailing Address - Street 1:8401 TRADEWINDS DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32456-6157
Mailing Address - Country:US
Mailing Address - Phone:850-478-1312
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:301 20TH ST
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-3301
Practice Address - Country:US
Practice Address - Phone:850-227-7070
Practice Address - Fax:850-227-1989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65165207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26155OtherBCBS OF FLORIDA
FL376567900Medicaid
FLK9321Medicare ID - Type Unspecified
FL376567900Medicaid