Provider Demographics
NPI:1356315311
Name:NYSTROM, DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:NYSTROM
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 1:405 S CLARK ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3047
Mailing Address - Country:US
Mailing Address - Phone:712-792-2222
Mailing Address - Fax:712-792-3875
Practice Address - Street 1:405 S CLARK ST
Practice Address - Street 2:SUITE # 230
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3065
Practice Address - Country:US
Practice Address - Phone:712-792-2222
Practice Address - Fax:712-792-3875
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0469395Medicaid
IA0469395Medicaid
IAI39806Medicare UPIN