Provider Demographics
NPI:1932304060
Name:STADSVOLD, CHAD ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:ALLEN
Last Name:STADSVOLD
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 1:2800 PIERCE ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-3755
Mailing Address - Country:US
Mailing Address - Phone:712-279-3754
Mailing Address - Fax:712-279-3644
Practice Address - Street 1:2800 PIERCE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-3755
Practice Address - Country:US
Practice Address - Phone:712-279-3754
Practice Address - Fax:712-279-3644
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR8139207R00000X
IA4175208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00606Medicaid
IA00606Medicaid