Basic Information
| Provider Information | |||||||||
| NPI: | 1881699890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANNENFELDT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | STE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 855 ILLINI DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612822904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092812090 | ||||||||
| FaxNumber: | 3092812099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036059049 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 020348 | 01 | HEALTH ALLIANCE | OTHER | 20127 | 01 | IOWA HEALTH SOLUTIONS | OTHER | 97788 | 01 | IA | WELLMARK BC/BS | OTHER | IL0120 | 01 | JOHN DEERE HEALTH PLAN | OTHER | 036059049 | 05 | IL | MEDICAID | 4796890014 | 01 | DMERC | OTHER | 97835 | 01 | IA | WELLMARK BC/BS | OTHER |