Healthcare Provider Details

I. General information

NPI: 1427169192
Provider Name (Legal Business Name): JON DT KAMMERER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 8TH AVE W
CRESCO IA
52136-1064
US

IV. Provider business mailing address

321 8TH AVE W
CRESCO IA
52136-1064
US

V. Phone/Fax

Practice location:
  • Phone: 563-547-2022
  • Fax: 563-547-3448
Mailing address:
  • Phone: 563-547-2022
  • Fax: 563-547-3448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR-7243
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier0443119
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: