1124065313 NPI number — KENNETH JAY IVERSON MD

Table of content: KENNETH JAY IVERSON MD (NPI 1124065313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124065313 NPI number — KENNETH JAY IVERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVERSON
Provider First Name:
KENNETH
Provider Middle Name:
JAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124065313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RTE 12 BLDG 449 ATTN PROFESSIONAL AFFAIRS
Provider Second Line Business Mailing Address:
NAVAL HEALTH CARE NEW ENGLAND GROTON
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06349-5600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-694-2377
Provider Business Mailing Address Fax Number:
860-694-2590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
43 SMITH RD
Provider Second Line Business Practice Location Address:
NAVAL HEALTH CARE NEW ENGLAND NEWPORT
Provider Business Practice Location Address City Name:
NEWPORT
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02841-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-694-2377
Provider Business Practice Location Address Fax Number:
860-694-3590
Provider Enumeration Date:
05/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME0061931 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)