1164416467 NPI number — DR. ROY A DOORENBOS MD

Table of content: DR. ROY A DOORENBOS MD (NPI 1164416467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164416467 NPI number — DR. ROY A DOORENBOS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOORENBOS
Provider First Name:
ROY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164416467
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/24/2006
NPI Reactivation Date:
03/29/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 780
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRINNELL
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50112-0780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-236-2500
Provider Business Mailing Address Fax Number:
641-236-2539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRINNELL
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50112-0780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-236-2500
Provider Business Practice Location Address Fax Number:
641-236-2539
Provider Enumeration Date:
09/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  25226 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DE1784 . This is a "RR MEDICARE GROUP #" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 421300342501120001 . This is a "TRICARE NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 6037523 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0294322 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25244 . This is a "BCBS PROV #" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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