1083691190 NPI number — CLAY R DAHLQUIST DO

Table of content: CLAY R DAHLQUIST DO (NPI 1083691190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083691190 NPI number — CLAY R DAHLQUIST DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAHLQUIST
Provider First Name:
CLAY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1083691190
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
312 9TH ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAVERLY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50677-2929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-352-4120
Provider Business Mailing Address Fax Number:
319-352-3992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 AMHEARST BLVD
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
NASHUA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50658-9712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-435-4133
Provider Business Practice Location Address Fax Number:
641-435-4003
Provider Enumeration Date:
12/29/2005

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:  03250 , 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)





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