Provider Demographics
NPI:1386641165
Name:LIDTKE, ROY (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:LIDTKE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 BLAIRS FERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302
Mailing Address - Country:US
Mailing Address - Phone:319-363-8854
Mailing Address - Fax:319-363-0807
Practice Address - Street 1:1215 BLAIRS FERRY RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-3016
Practice Address - Country:US
Practice Address - Phone:319-363-8854
Practice Address - Fax:319-363-0807
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA555213E00000X
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
6000038COtherBCBS
L84513Medicare ID - Type Unspecified
U34921Medicare UPIN