Provider Demographics
NPI:1821155714
Name:NEUSTROM, KIRK W (DPM)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:W
Last Name:NEUSTROM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 BROOKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-2734
Mailing Address - Country:US
Mailing Address - Phone:515-221-9330
Mailing Address - Fax:
Practice Address - Street 1:1228 8TH ST STE 105
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-2624
Practice Address - Country:US
Practice Address - Phone:515-221-9330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA446213EP1101X, 213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0083139Medicaid
IAT38822Medicare UPIN
IA06958Medicare ID - Type Unspecified