Provider Demographics
NPI:1578149597
Name:IVERSEN, CHRISTIAN (MD)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:IVERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1244 FORT WASHINGTON AVE STE E2
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-1743
Mailing Address - Country:US
Mailing Address - Phone:215-646-1686
Mailing Address - Fax:
Practice Address - Street 1:1244 FORT WASHINGTON AVE STE E2
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-1743
Practice Address - Country:US
Practice Address - Phone:215-646-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-21
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD482171207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program