Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 1396 | AZ |
NPI | 1003970658 |
---|---|
Provider Name | Robert Iverson |
First Address | San Antonio, TX 78213-1370 |
Second Address | Tucson, AZ 85705-1784 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
V03556 | (02) | AZ |