Healthcare Provider Details

I. General information

NPI: 1750590246
Provider Name (Legal Business Name): CHARLES D CIBULA D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4508 CHADWICK RD CEDAR VALLEY PODIATRY PC
CEDAR FALLS IA
50613-7958
US

IV. Provider business mailing address

4508 CHADWICK RD CEDAR VALLEY PODIATRY PC
CEDAR FALLS IA
50613-7958
US

V. Phone/Fax

Practice location:
  • Phone: 319-277-4508
  • Fax: 319-277-8908
Mailing address:
  • Phone: 319-277-4508
  • Fax: 319-277-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberBM25495090685
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000836
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: