Basic Information
| Provider Information | |||||||||
| NPI: | 1861445223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUVEN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2758 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507042758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198336100 | ||||||||
| FaxNumber: | 3198336102 | ||||||||
| Practice Location | |||||||||
| Address1: | 1731 W RIDGEWAY AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507014591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3198336100 | ||||||||
| FaxNumber: | 3198336102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/09/2007 | ||||||||
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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 | 208600000X | 23463 | IA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 42141730701 | 01 | IA | JOHN DEERE HEALTH CARE | OTHER | 1203869 | 05 | IA | MEDICAID | 19288 | 01 | IA | WELLMARK INS PLAN | OTHER |