1639461007 NPI number — GWEN GEORGE LUEPKE M.D.

Table of content: GWEN GEORGE LUEPKE M.D. (NPI 1639461007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639461007 NPI number — GWEN GEORGE LUEPKE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUEPKE
Provider First Name:
GWEN
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GEORGE
Provider Other First Name:
GWEN
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639461007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4612 PALM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50310-3795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-252-1421
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2725 MERLE HAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50310-1134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-279-9766
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2011

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:  24157 , 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)