Healthcare Provider Details

I. General information

NPI: 1003878349
Provider Name (Legal Business Name): MARK IVERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 RIVER ST SUITE 204
MONTPELIER VT
05602-3792
US

IV. Provider business mailing address

81 RIVER ST SUITE 204
MONTPELIER VT
05602-3792
US

V. Phone/Fax

Practice location:
  • Phone: 802-229-9554
  • Fax: 802-229-5906
Mailing address:
  • Phone: 802-229-9554
  • Fax: 802-229-5906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number042.0007517
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: