Provider Demographics
NPI:1821295494
Name:DONALD R WIRTANEN DO
Entity Type:Organization
Organization Name:DONALD R WIRTANEN DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:L
Authorized Official - Last Name:KLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-664-1400
Mailing Address - Street 1:202 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52537-1425
Mailing Address - Country:US
Mailing Address - Phone:641-664-1400
Mailing Address - Fax:641-664-1410
Practice Address - Street 1:202 N MADISON ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:IA
Practice Address - Zip Code:52537-1425
Practice Address - Country:US
Practice Address - Phone:641-664-1400
Practice Address - Fax:641-664-1410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1821295494Medicaid
IAI7554Medicare PIN
IAI7554Medicare ID - Type Unspecified
IA1821295494Medicaid
IAS65087Medicare UPIN