Healthcare Provider Details

I. General information

NPI: 1679565568
Provider Name (Legal Business Name): WILLIAM NOLLEY VEREEN III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JACKSON ST
SIOUX CITY IA
51105-1431
US

IV. Provider business mailing address

1000 JACKSON ST
SIOUX CITY IA
51105-1431
US

V. Phone/Fax

Practice location:
  • Phone: 712-252-0501
  • Fax: 712-252-2024
Mailing address:
  • Phone: 712-252-0501
  • Fax: 712-252-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2409
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier7792900
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier0062208
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: