Provider Demographics
NPI:1669407581
Name:IVERSON, KRISTI ANN (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTI
Middle Name:ANN
Last Name:IVERSON
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 W SOUTHERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4903
Mailing Address - Country:US
Mailing Address - Phone:480-961-1702
Mailing Address - Fax:480-893-8172
Practice Address - Street 1:85 W COMBS RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-9107
Practice Address - Country:US
Practice Address - Phone:602-239-4286
Practice Address - Fax:602-474-2324
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2585152W00000X
AZOPT-002846152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN493717100Medicaid
MN493717100Medicaid
MN410001655Medicare ID - Type Unspecified
MI1019428OtherDEA