Provider Demographics
NPI:1023570306
Name:CEDAR VALLEY PODIATRY PC
Entity Type:Organization
Organization Name:CEDAR VALLEY PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:G
Authorized Official - Last Name:CERVETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:319-277-4508
Mailing Address - Street 1:4508 CHADWICK RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-7958
Mailing Address - Country:US
Mailing Address - Phone:319-277-4508
Mailing Address - Fax:319-277-8908
Practice Address - Street 1:201 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:OELWEIN
Practice Address - State:IA
Practice Address - Zip Code:50662-2447
Practice Address - Country:US
Practice Address - Phone:319-277-4508
Practice Address - Fax:319-277-8908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0469726Medicaid