Provider Demographics
NPI:1578555314
Name:BAMBARA, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:BAMBARA
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 1:2498 265TH ST
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-9644
Mailing Address - Country:US
Mailing Address - Phone:641-672-9341
Mailing Address - Fax:
Practice Address - Street 1:1609 N ANKENY BLVD
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4166
Practice Address - Country:US
Practice Address - Phone:515-964-2772
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27347207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAE42104Medicare UPIN