Provider Demographics
NPI:1346228970
Name:KETTELKAMP, JAMES E (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:KETTELKAMP
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 1:4480 UTICA RIDGE RD
Mailing Address - Street 2:SUITE 2230
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1644
Mailing Address - Country:US
Mailing Address - Phone:563-742-5150
Mailing Address - Fax:563-742-5175
Practice Address - Street 1:4480 UTICA RIDGE RD
Practice Address - Street 2:SUITE 2230
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1644
Practice Address - Country:US
Practice Address - Phone:563-742-5150
Practice Address - Fax:563-742-5175
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1346228970Medicaid
IA3144113Medicaid
IA110228451OtherRR MEDICARE
IA1750347035Medicaid
IL200715008Medicare PIN
IA3144113Medicaid
IA1750347035Medicaid