Provider Demographics
NPI:1083691190
Name:DAHLQUIST, CLAY R (DO)
Entity Type:Individual
Prefix:
First Name:CLAY
Middle Name:R
Last Name:DAHLQUIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 9TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-2929
Mailing Address - Country:US
Mailing Address - Phone:319-352-4120
Mailing Address - Fax:319-352-3992
Practice Address - Street 1:80 AMHEARST BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:NASHUA
Practice Address - State:IA
Practice Address - Zip Code:50658-9712
Practice Address - Country:US
Practice Address - Phone:641-435-4133
Practice Address - Fax:641-435-4003
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI14960Medicare PIN
IAH09678Medicare UPIN