Provider Demographics
NPI:1962469395
Name:IVERSON, GREGORY D (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:IVERSON
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:PO BOX 865
Mailing Address - Street 2:
Mailing Address - City:COALVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84017-0865
Mailing Address - Country:US
Mailing Address - Phone:435-336-4403
Mailing Address - Fax:435-336-5570
Practice Address - Street 1:142 SOUTH 50 EAST
Practice Address - Street 2:
Practice Address - City:COALVILLE
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:435-336-4403
Practice Address - Fax:435-336-5570
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE365207Q00000X
UT7261660-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine