Provider Demographics
NPI:1922042894
Name:KETTELKAMP, RICHARD T (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:KETTELKAMP
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 1:202 10TH ST SE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-2404
Mailing Address - Country:US
Mailing Address - Phone:319-364-7101
Mailing Address - Fax:
Practice Address - Street 1:202 10TH ST SE
Practice Address - Street 2:SUITE 225
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2404
Practice Address - Country:US
Practice Address - Phone:319-364-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3618207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1922042894Medicaid
IAP00823157OtherRR MEDICARE
IAIB1600003Medicare PIN
IAP00823157OtherRR MEDICARE
IAIB1598003Medicare PIN