Basic Information
| Provider Information | |||||||||
| NPI: | 1023026689 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANSSEN | ||||||||
| FirstName: | GARY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 6TH AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503142607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156438672 | ||||||||
| FaxNumber: | 5156432784 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 E DETROIT AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANOLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501251860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159615324 | ||||||||
| FaxNumber: | 5159610116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207Q00000X | 01785 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3220822 | 05 | IA | MEDICAID |