Provider Demographics
NPI:1356428536
Name:MCLAWS, IVAN DALE (DPM)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:DALE
Last Name:MCLAWS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85547-0603
Mailing Address - Country:US
Mailing Address - Phone:928-474-9242
Mailing Address - Fax:928-474-9241
Practice Address - Street 1:200 E LONE PINE ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5519
Practice Address - Country:US
Practice Address - Phone:928-474-9242
Practice Address - Fax:928-474-9241
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0252213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0636450001Medicare NSC
AZT41939Medicare UPIN
AZ27063665AMedicare ID - Type Unspecified