Provider Demographics
NPI:1952484909
Name:DE JONG, CHESTER PENN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:PENN
Last Name:DE JONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:803 S GREENE ST
Practice Address - Street 2:
Practice Address - City:ROCK RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:51246-1948
Practice Address - Country:US
Practice Address - Phone:712-472-3716
Practice Address - Fax:712-472-2878
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0638700Medicaid
IA4075648Medicaid
IA0250498Medicaid
IA1075648Medicaid
IA0250498Medicaid
IA0638700Medicaid
IAI5035Medicare ID - Type UnspecifiedIND MEDICARE #
IA1075648Medicaid