Provider Demographics
NPI:1437267713
Name:ROY A DOORENBOS MD
Entity Type:Organization
Organization Name:ROY A DOORENBOS MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOORENBOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:641-236-2500
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-0780
Mailing Address - Country:US
Mailing Address - Phone:641-236-2500
Mailing Address - Fax:641-236-2539
Practice Address - Street 1:210 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-0780
Practice Address - Country:US
Practice Address - Phone:641-236-2500
Practice Address - Fax:641-236-2539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25226207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA6037523Medicaid
IA0294322Medicaid
25244Medicare PIN
IA6037523Medicaid
I8673Medicare PIN