Basic Information
| Provider Information | |||||||||
| NPI: | 1710091251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOEKSTRA | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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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: | 08/19/2006 | ||||||||
| LastUpdateDate: | 11/10/2012 | ||||||||
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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 | 174400000X | 01585 | IA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1710091251 | 05 | IA | MEDICAID | P00758400 | 01 | IA | RR MEDICARE | OTHER | 1097592 | 05 | IA | MEDICAID |