Basic Information
| Provider Information | |||||||||
| NPI: | 1033161096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGELKEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DANIEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | DUBUQUE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 520017320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5635898796 | ||||||||
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| Practice Location | |||||||||
| Address1: | 250 MERCY DR | ||||||||
| Address2: | |||||||||
| City: | DUBUQUE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 520017320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5635898796 | ||||||||
| FaxNumber: | 5635898776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 12/11/2007 | ||||||||
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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 | 2085R0202X | 36070 | IA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0488361 | 05 | IA | MEDICAID | 20549 | 01 | IA | BCBS PIN | OTHER | 34852900 | 05 | WI | MEDICAID |