Basic Information
Provider Information | |||||||||
NPI: | 1710095039 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOOLITTLE | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 621 S ILLINOIS AVE STE 103 | ||||||||
Address2: |   | ||||||||
City: | MASON CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 504015489 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6414283041 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1010 4TH ST SW STE 120 | ||||||||
Address2: |   | ||||||||
City: | MASON CITY | ||||||||
State: | IA | ||||||||
PostalCode: | 504012856 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6414286020 | ||||||||
FaxNumber: | 6414287803 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2006 | ||||||||
LastUpdateDate: | 08/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34730 | IA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 04-38088 | KS | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 110173309 | 01 |   | MEDICARE | OTHER |