Basic Information
| Provider Information | |||||||||
| NPI: | 1275502007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAYERI | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCIVOR | ||||||||
| OtherFirstName: | JUDITH | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152372974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 22ND ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WEST DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502661443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154406622 | ||||||||
| FaxNumber: | 5154406698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02946 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.