Basic Information
Provider Information | |||||||||
NPI: | 1639518426 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELWOOD | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2710 SAINT FRANCIS DR STE 419 | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 507025634 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192725000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2710 SAINT FRANCIS DR STE 419 | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 50702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192725000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2013 | ||||||||
LastUpdateDate: | 06/28/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | R-10776 | IA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207LP2900X | MD-44932 | IA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.