Provider Demographics
NPI:1376838730
Name:DEJONG, KATIE ALISSA (DO)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ALISSA
Last Name:DEJONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 FOREST GLN
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52245-1625
Mailing Address - Country:US
Mailing Address - Phone:313-333-8056
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:GH-C43
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1007
Practice Address - Country:US
Practice Address - Phone:313-333-8056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IAR-9304207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program