Provider Demographics
NPI:1265432264
Name:MENADUE, MARK C (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:MENADUE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1609 N. ANKENY BLVD
Mailing Address - Street 2:#200
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021
Mailing Address - Country:US
Mailing Address - Phone:515-964-2772
Mailing Address - Fax:
Practice Address - Street 1:1609 N ANKENY BLVD
Practice Address - Street 2:#200
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-4165
Practice Address - Country:US
Practice Address - Phone:515-964-2772
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02255207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA03577Medicare UPIN