Provider Demographics
NPI:1760494074
Name:IVERSEN, MICHAEL GELLATLY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GELLATLY
Last Name:IVERSEN
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 1:525 N BRENTWOOD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-7124
Mailing Address - Country:US
Mailing Address - Phone:936-634-3627
Mailing Address - Fax:936-633-2398
Practice Address - Street 1:525 N BRENTWOOD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-7124
Practice Address - Country:US
Practice Address - Phone:936-634-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E73193Medicare UPIN
TX8K3409Medicare PIN