Basic Information
| Provider Information | |||||||||
| NPI: | 1881927341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR ROY LIDTKE PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 284 | ||||||||
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| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503010280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168837100 | ||||||||
| FaxNumber: | 5168837474 | ||||||||
| Practice Location | |||||||||
| Address1: | 1026 A AVE NE | ||||||||
| Address2: | SUITE 5000 | ||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524025036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3199295572 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2009 | ||||||||
| LastUpdateDate: | 09/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | LIDTKE | ||||||||
| AuthorizedOfficialFirstName: | ROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3199295572 | ||||||||
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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 | 213E00000X | 00555 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.