Provider Demographics
NPI:1922621291
Name:IVERSON, JAMES III
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:IVERSON
Suffix:III
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:PO BOX 7846
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73506-1846
Mailing Address - Country:US
Mailing Address - Phone:580-280-3770
Mailing Address - Fax:
Practice Address - Street 1:6921 W GORE BLVD APT 601
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5369
Practice Address - Country:US
Practice Address - Phone:580-284-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKL083091854OtherDRIVER'S LICENSE