Healthcare Provider Details

I. General information

NPI: 1811933880
Provider Name (Legal Business Name): GREGORY A JEPPESEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MERCY DR
COUNCIL BLUFFS IA
51503-3128
US

IV. Provider business mailing address

4750 HEMPSTEAD STATION DR
KETTERING OH
45429-5164
US

V. Phone/Fax

Practice location:
  • Phone: 712-328-5230
  • Fax:
Mailing address:
  • Phone: 800-875-0136
  • Fax: 937-619-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34008307
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4162
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number793
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: