Basic Information
| Provider Information | |||||||||
| NPI: | 1154481273 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVID E DRAKE DO PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 CENTER | ||||||||
| Address2: | #3 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152888000 | ||||||||
| FaxNumber: | 5152884073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 05/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | DRAKE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5152888000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 02908 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1154481273 | 01 | IA | WELLMARK BCBS | OTHER | 1154481273 | 05 | IA | MEDICAID | DP1972 | 01 | IA | RR MEDICARE | OTHER | 2121004 | 05 | IA | MEDICAID |