Provider Demographics
NPI:1750393781
Name:REVERON, IVAN J (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:J
Last Name:REVERON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:203 N WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0233
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:509-444-7806
Practice Address - Street 1:5901 N LIDGERWOOD ST STE 126
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1122
Practice Address - Country:US
Practice Address - Phone:509-434-1990
Practice Address - Fax:509-340-8986
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD60063800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine