Provider Demographics
NPI:1770513970
Name:IVERSON, GODELA R (MD)
Entity type:Individual
Prefix:
First Name:GODELA
Middle Name:R
Last Name:IVERSON
Suffix:
Gender:F
Credentials:MD
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 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:701-364-8078
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3278207RI0200X
MN28275207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1022OtherNDBS #
ND91481IVOtherMNBS #
ND4864OtherNDBS #
ND142019OtherUCARE #
MN2580OtherNDBS #
NDDA9011015543OtherPREFERRED ONE #
ND12383Medicaid
NDND200028OtherLHS #
ND10750OtherNDBS #
ND902104OtherAMERICA'S PPO/ARAZ #
ND9200082OtherMEDICA #
NDHP25778OtherHEALTHPARTNERS #
MN50168IVOtherMNBS #
ND9200119OtherMEDICA #
ND142019OtherUCARE #
ND91481IVOtherMNBS #
MN50168IVOtherMNBS #
ND12383Medicaid