Healthcare Provider Details

I. General information

NPI: 1902596984
Provider Name (Legal Business Name): DOLIDO IKALABA LUSE SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5170 16TH AVENUE SOUTHWEST 13
CEDAR RAPIDS IA
52404-6708
US

IV. Provider business mailing address

5170 16TH AVENUE SOUTHWEST 13
CEDAR RAPIDS IA
52404-6708
US

V. Phone/Fax

Practice location:
  • Phone: 319-899-7043
  • Fax:
Mailing address:
  • Phone: 319-899-7043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberLUV782
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: