Provider Demographics
NPI:1750302634
Name:IVERSON, RONALD (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:IVERSON
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:PO BOX 50770
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82605-0770
Mailing Address - Country:US
Mailing Address - Phone:307-333-6910
Mailing Address - Fax:307-333-6912
Practice Address - Street 1:1233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2926
Practice Address - Country:US
Practice Address - Phone:307-333-6910
Practice Address - Fax:307-333-6912
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3485A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY307785OtherBLUE SHIELD
WY305753OtherBLUE SHIELD
WY82601D018OtherWPS TRIWEST
WY104439700Medicaid
WY930067310OtherRAILROAD MEDICARE
WY930013242OtherRAILROAD MEDICARE
WY82601D018OtherWPS TRIWEST