Healthcare Provider Details

I. General information

NPI: 1851312557
Provider Name (Legal Business Name): MARK M ZITTERGRUEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 A AVE NE SUITE 5000
CEDAR RAPIDS IA
52402-5036
US

IV. Provider business mailing address

1026 A AVE NE SUITE 5000
CEDAR RAPIDS IA
52402-5036
US

V. Phone/Fax

Practice location:
  • Phone: 319-368-5757
  • Fax:
Mailing address:
  • Phone: 319-368-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28303
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number28303
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: