Provider Demographics
NPI:1821085200
Name:DOORENBOS, DARYL ERWIN (MD)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:ERWIN
Last Name:DOORENBOS
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 1:1775 7TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-2869
Mailing Address - Country:US
Mailing Address - Phone:712-546-3640
Mailing Address - Fax:712-546-3644
Practice Address - Street 1:194 6TH AVE NE
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-3716
Practice Address - Country:US
Practice Address - Phone:712-546-3640
Practice Address - Fax:712-546-3644
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA07396OtherWELLMARK BC/BS
IA0073965Medicaid
IA0073965Medicaid
IAA14329Medicare UPIN