Provider Demographics
NPI:1851366702
Name:IVERS, VINCENT M
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:M
Last Name:IVERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065165208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376567900Medicaid
FL376567900Medicaid
FL26155TMedicare ID - Type Unspecified