Basic Information
| Provider Information | |||||||||
| NPI: | 1699824607 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVERY | ||||||||
| FirstName: | LATONJA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10900 WORLD TRADE BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192371337 | ||||||||
| FaxNumber: | 9192371625 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 STADIUM DRIVE | ||||||||
| Address2: | STE 104 | ||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196235939 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2004-01519 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5900011 | 05 | NC | MEDICAID |