Provider Demographics
NPI:1558349092
Name:KAVLOCK, RENAE ANNETTE (MD)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:ANNETTE
Last Name:KAVLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 WESTOWN PKWY STE 236
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6720
Mailing Address - Country:US
Mailing Address - Phone:515-401-1950
Mailing Address - Fax:515-401-1955
Practice Address - Street 1:4201 WESTOWN PKWY STE 236
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-6720
Practice Address - Country:US
Practice Address - Phone:515-401-1950
Practice Address - Fax:515-401-1955
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35028207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA35028OtherTRICARE PROVIDER #
IA34842OtherBLUE SHIELD PROVIDER #
IA240172OtherMIDLANDS PROVIDER #
IAP00041925OtherRAILROAD MEDICARE #
IA0298356Medicaid
IAIA01A3OtherJOHN DEERE PROVIDER #
IA34842OtherBLUE SHIELD PROVIDER #
IAH87273Medicare UPIN