Provider Demographics
NPI:1891776365
Name:HUISMAN, ETHAN EVERETT (OD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:EVERETT
Last Name:HUISMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 SE UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-8933
Mailing Address - Country:US
Mailing Address - Phone:515-987-3937
Mailing Address - Fax:515-987-3930
Practice Address - Street 1:1350 SE UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WAUKEE
Practice Address - State:IA
Practice Address - Zip Code:50263-8933
Practice Address - Country:US
Practice Address - Phone:515-987-3937
Practice Address - Fax:515-987-3930
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02216152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAU88983Medicare UPIN
IAI12377Medicare ID - Type UnspecifiedMEDICARE