Provider Demographics
NPI:1760757561
Name:MORRIS, IVAN (DO)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MORRIS
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 1:1790 S CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-9301
Mailing Address - Country:US
Mailing Address - Phone:517-881-6864
Mailing Address - Fax:
Practice Address - Street 1:1568 LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3707
Practice Address - Country:US
Practice Address - Phone:517-913-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine