1770513970 NPI number — GODELA R IVERSON MD

Table of content: GODELA R IVERSON MD (NPI 1770513970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770513970 NPI number — GODELA R IVERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVERSON
Provider First Name:
GODELA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1770513970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58108-6001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-364-3300
Provider Business Mailing Address Fax Number:
701-364-8906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 32ND AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-364-8000
Provider Business Practice Location Address Fax Number:
701-364-8078
Provider Enumeration Date:
07/04/2006

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: 207RI0200X , with the licence number:  3278 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RI0200X , with the licence number: 28275 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1022 . This is a "NDBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 91481IV . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 4864 . This is a "NDBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 142019 . This is a "UCARE #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 2580 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DA9011015543 . This is a "PREFERRED ONE #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 12383 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: ND200028 . This is a "LHS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 10750 . This is a "NDBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 902104 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 9200082 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: HP25778 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 50168IV . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9200119 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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