Healthcare Provider Details

I. General information

NPI: 1205838984
Provider Name (Legal Business Name): JOHN D. INGRAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2016 1ST AVE S
DENISON IA
51442-2210
US

IV. Provider business mailing address

100 MEDICAL PKWY STE A
DENISON IA
51442-2614
US

V. Phone/Fax

Practice location:
  • Phone: 712-263-3388
  • Fax: 712-263-1777
Mailing address:
  • Phone: 712-263-3388
  • Fax: 712-263-1777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29356
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: