Basic Information
| Provider Information | |||||||||
| NPI: | 1871084384 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MED MANAGEMENT ASSOCIATES OF IOWA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7272 WURZBACH RD STE 601 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782404803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106153483 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2571 GUTHRIE AVE | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152657219 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2018 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | KOTWAL | ||||||||
| AuthorizedOfficialFirstName: | NEVILLE | ||||||||
| AuthorizedOfficialMiddleName: | HOMI | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2106153483 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 35543 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 35443 | 01 | IA | LICENSE - MD | OTHER |