Provider Demographics
NPI:1184623985
Name:WIRTANEN, DONALD RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:RICHARD
Last Name:WIRTANEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA82100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1821295494Medicaid
IA1184623985OtherMEDICARE
MO242195006Medicaid
A02796Medicare UPIN
IAI7554Medicare PIN