Provider Demographics
NPI:1548235096
Name:DIERCKS-OETZEL, KIMBERLY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:DIERCKS-OETZEL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2322 E KIMBERLY RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-7205
Mailing Address - Country:US
Mailing Address - Phone:563-359-0899
Mailing Address - Fax:563-441-1577
Practice Address - Street 1:2322 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-7205
Practice Address - Country:US
Practice Address - Phone:563-359-0899
Practice Address - Fax:563-441-1577
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05653111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0088617Medicaid
IA10026Medicare ID - Type Unspecified
IAU35782Medicare UPIN