Provider Demographics
NPI:1053948646
Name:IVERSON, STEFAN (DO)
Entity type:Individual
Prefix:
First Name:STEFAN
Middle Name:
Last Name:IVERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 PINON DR
Mailing Address - Street 2:
Mailing Address - City:PONCHA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81242-5084
Mailing Address - Country:US
Mailing Address - Phone:270-562-5003
Mailing Address - Fax:
Practice Address - Street 1:1000 RUSH DR
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9627
Practice Address - Country:US
Practice Address - Phone:719-530-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO75732208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery