Provider Demographics
NPI:1164416467
Name:DOORENBOS, ROY A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:A
Last Name:DOORENBOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-0780
Mailing Address - Country:US
Mailing Address - Phone:641-236-2500
Mailing Address - Fax:641-236-2539
Practice Address - Street 1:210 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-0780
Practice Address - Country:US
Practice Address - Phone:641-236-2500
Practice Address - Fax:641-236-2539
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2007-10-12
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
IA25226207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IADE1784OtherRR MEDICARE GROUP #
IA421300342501120001OtherTRICARE NUMBER
IA6037523Medicaid
IA0294322Medicaid
IA25244OtherBCBS PROV #
IA0294322Medicaid
IADE1784OtherRR MEDICARE GROUP #
IA6037523Medicaid