Basic Information
Provider Information | |||||||||
NPI: | 1720145634 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KAUFMAN | ||||||||
FirstName: | OLAF | ||||||||
MiddleName: | PETER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4200 UNIVERSITY AVE | ||||||||
Address2: | SUITE 104 | ||||||||
City: | WEST DES MOINES | ||||||||
State: | IA | ||||||||
PostalCode: | 502665945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5159610453 | ||||||||
FaxNumber: | 5159612714 | ||||||||
Practice Location | |||||||||
Address1: | 12368 STRATFORD DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | CLIVE | ||||||||
State: | IA | ||||||||
PostalCode: | 503258162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5152269810 | ||||||||
FaxNumber: | 5152268408 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2007 | ||||||||
LastUpdateDate: | 04/14/2014 | ||||||||
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 | 2085R0202X | 34964 | IA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 23324 | NE | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 104349 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 52264 | MN | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | ENROLLED | 05 | MN |   | MEDICAID | ENROLLED | 05 | IA |   | MEDICAID |