Basic Information
| Provider Information | |||||||||
| NPI: | 1063525277 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN DEERE MEDICAL GROUP OF WATERLOO, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 S HACKETT RD | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507013500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192741000 | ||||||||
| FaxNumber: | 3192926526 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 S HACKETT RD | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507013500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192741000 | ||||||||
| FaxNumber: | 3192926526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOEKSTRA | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3192741016 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 01585 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1097592 | 05 | IA | MEDICAID |