Basic Information
| Provider Information | |||||||||
| NPI: | 1770513970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IVERSON | ||||||||
| FirstName: | GODELA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 3278 | ND | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 28275 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 1022 | 01 | ND | NDBS # | OTHER | 91481IV | 01 | ND | MNBS # | OTHER | 4864 | 01 | ND | NDBS # | OTHER | 142019 | 01 | ND | UCARE # | OTHER | 2580 | 01 | MN | NDBS # | OTHER | DA9011015543 | 01 | ND | PREFERRED ONE # | OTHER | 12383 | 05 | ND | MEDICAID | ND200028 | 01 | ND | LHS # | OTHER | 10750 | 01 | ND | NDBS # | OTHER | 902104 | 01 | ND | AMERICA'S PPO/ARAZ # | OTHER | 9200082 | 01 | ND | MEDICA # | OTHER | HP25778 | 01 | ND | HEALTHPARTNERS # | OTHER | 50168IV | 01 | MN | MNBS # | OTHER | 9200119 | 01 | ND | MEDICA # | OTHER |