Healthcare Provider Details

I. General information

NPI: 1356428536
Provider Name (Legal Business Name): IVAN DALE MCLAWS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E LONE PINE ST
PAYSON AZ
85541-5519
US

IV. Provider business mailing address

PO BOX 603
PAYSON AZ
85547-0603
US

V. Phone/Fax

Practice location:
  • Phone: 928-474-9242
  • Fax: 928-474-9241
Mailing address:
  • Phone: 928-474-9242
  • Fax: 928-474-9241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0252
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: