Provider Demographics
NPI:1588614069
Name:GERDES-BOELENS, MICHELLE R (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:R
Last Name:GERDES-BOELENS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:MICKI
Other - Middle Name:RENEE
Other - Last Name:GERDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:501 S WHITE ST
Mailing Address - Street 2:SUITE 27
Mailing Address - City:MT PLEASANT
Mailing Address - State:IA
Mailing Address - Zip Code:52641-2603
Mailing Address - Country:US
Mailing Address - Phone:319-385-6756
Mailing Address - Fax:319-385-6759
Practice Address - Street 1:501 S WHITE ST
Practice Address - Street 2:SUITE 27
Practice Address - City:MT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-2603
Practice Address - Country:US
Practice Address - Phone:319-385-6756
Practice Address - Fax:319-385-6759
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00790213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAV09318Medicare UPIN
IAI17541Medicare PIN