Provider Demographics
NPI:1598733891
Name:WILLE, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:WILLE
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:PO BOX 1824
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-1824
Mailing Address - Country:US
Mailing Address - Phone:319-369-4505
Mailing Address - Fax:319-369-4677
Practice Address - Street 1:402 SIEGEL ST
Practice Address - Street 2:
Practice Address - City:TAMA
Practice Address - State:IA
Practice Address - Zip Code:52339-2302
Practice Address - Country:US
Practice Address - Phone:641-484-3333
Practice Address - Fax:641-484-3208
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4168401Medicaid
IAI11467Medicare ID - Type Unspecified
IA4168401Medicaid