Basic Information
| Provider Information | |||||||||
| NPI: | 1164512711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYCKHOLM | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | C21-GH | ||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3194675346 | ||||||||
| FaxNumber: | 8043427619 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | C21-GH | ||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3194675346 | ||||||||
| FaxNumber: | 3193538383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 27102 | IA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 6028888 | 05 | VA | MEDICAID |