Provider Demographics
NPI:1699824607
Name:IVERY, LATONJA M (M D)
Entity Type:Individual
Prefix:
First Name:LATONJA
Middle Name:M
Last Name:IVERY
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 WORLD TRADE BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617
Mailing Address - Country:US
Mailing Address - Phone:919-237-1337
Mailing Address - Fax:919-237-1625
Practice Address - Street 1:1001 STADIUM DRIVE
Practice Address - Street 2:STE 104
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587
Practice Address - Country:US
Practice Address - Phone:919-623-5939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-01519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900011Medicaid
NC2035808Medicare PIN
NC5900011Medicaid