Basic Information
| Provider Information | |||||||||
| NPI: | 1003819624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAVIER | ||||||||
| FirstName: | FELIPE | ||||||||
| MiddleName: | COSCOLLUELA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2710 SAINT FRANCIS DR STE 411 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192725000 | ||||||||
| FaxNumber: | 3192725825 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 SAINT FRANCIS DR STE 411 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192725000 | ||||||||
| FaxNumber: | 3192725825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 036-100466 | IL | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 208000000X | 036-100466 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 32545 | IA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207K00000X | 32545 | IA | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | O278374 | 05 | IA | MEDICAID | 203896410 | 05 | MO | MEDICAID | 421527584 | 01 | TRI-CARE GROUP NUMBER | OTHER | 33628 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 421527584003 | 05 | IL | MEDICAID | 42152758408 | 01 | JOHN DEERE | OTHER |