Provider Demographics
NPI:1225076029
Name:RAECKER, GREG EVAN (DO)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:EVAN
Last Name:RAECKER
Suffix:
Gender:M
Credentials:DO
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 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-833-6001
Mailing Address - Fax:319-833-6003
Practice Address - Street 1:1731 W RIDGEWAY AVE
Practice Address - Street 2:STE 101
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4591
Practice Address - Country:US
Practice Address - Phone:319-833-6001
Practice Address - Fax:319-833-6003
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA020872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA42141730793OtherJOHN DEERE HLTH INS PLAN
IA56258OtherWELLMARK INS PLAN
IA5030635Medicaid
IA42141730793OtherJOHN DEERE HLTH INS PLAN
IA5030635Medicaid