Healthcare Provider Details

I. General information

NPI: 1194987016
Provider Name (Legal Business Name): BETH R REPP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETH R KUTZBACH MD

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 TANGLEFOOT LN
BETTENDORF IA
52722-1650
US

IV. Provider business mailing address

4731 45TH STREET CT
ROCK ISLAND IL
61201-7102
US

V. Phone/Fax

Practice location:
  • Phone: 563-323-2020
  • Fax: 563-328-5694
Mailing address:
  • Phone: 309-793-2020
  • Fax: 309-793-2602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number50530
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number39738
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: