Healthcare Provider Details

I. General information

NPI: 1619110426
Provider Name (Legal Business Name): COREY JAMES STOTTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 S GRANDVIEW AVE
DUBUQUE IA
52003-8733
US

IV. Provider business mailing address

1440 S GRANDVIEW AVE
DUBUQUE IA
52003-8733
US

V. Phone/Fax

Practice location:
  • Phone: 319-290-2097
  • Fax:
Mailing address:
  • Phone: 319-290-2097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number51179
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number41108
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: