Healthcare Provider Details

I. General information

NPI: 1326187360
Provider Name (Legal Business Name): KATRINA IVERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST
DETROIT MI
48201-2119
US

IV. Provider business mailing address

3901 BEAUBIEN ST
DETROIT MI
48201-2119
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5260
  • Fax:
Mailing address:
  • Phone: 313-745-5260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2005-0263
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number4301091744
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: