1962217778 NPI number — NORTHWEST IOWA DERMATOLOGY LLC

Table of content: (NPI 1962217778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962217778 NPI number — NORTHWEST IOWA DERMATOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST IOWA DERMATOLOGY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1962217778
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKOBOJI
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51355-0751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-416-8776
Provider Business Mailing Address Fax Number:
515-513-0728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 N DODGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALGONA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50511-2636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-622-7060
Provider Business Practice Location Address Fax Number:
515-293-4481
Provider Enumeration Date:
02/10/2025

Additional Information

Authorized Official

Authorized Official Last Name:
MCCONNELL
Authorized Official First Name:
CAITLIN
Authorized Official Middle Name:
Authorized Official Title or Position:
ARNP, FNP-C
Authorized Official Telephone Number:
712-298-0748

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com