Provider Demographics
NPI:1760452205
Name:BOLLUYT, JEREMY E (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:E
Last Name:BOLLUYT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 23RD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-1158
Mailing Address - Country:US
Mailing Address - Phone:712-336-3750
Mailing Address - Fax:712-336-3730
Practice Address - Street 1:2700 23RD ST
Practice Address - Street 2:SUITE C
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1158
Practice Address - Country:US
Practice Address - Phone:712-336-3750
Practice Address - Fax:712-336-3730
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA3326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1187948Medicaid
IA1187948Medicaid