Healthcare Provider Details

I. General information

NPI: 1053780098
Provider Name (Legal Business Name): MR. JEREMY RICHARD DOLDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 UNIVERSITY ST.
PELLA IA
50219
US

IV. Provider business mailing address

1251 SANTA FE DR.
IOWA CITY IA
52246
US

V. Phone/Fax

Practice location:
  • Phone: 319-930-0493
  • Fax:
Mailing address:
  • Phone: 319-930-0493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: