Provider Demographics
NPI:1407832140
Name:KADEMIAN, JACK C (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:KADEMIAN
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-3375
Mailing Address - Fax:319-356-2220
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-3375
Practice Address - Fax:319-356-2220
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA358752085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0454769Medicaid
IA38058OtherWELLMARK BCBS
I25278Medicare UPIN
IA0454769Medicaid
IAP00273281Medicare PIN