Basic Information
| Provider Information | |||||||||
| NPI: | 1851366702 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVERS | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8401 TRADEWINDS DR | ||||||||
| Address2: | |||||||||
| City: | PORT ST JOE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504781312 | ||||||||
| FaxNumber: | 8504749060 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 20TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ST JOE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324563301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502277070 | ||||||||
| FaxNumber: | 8502271989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 06/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ME0065165 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 376567900 | 05 | FL | MEDICAID |