Provider Demographics
NPI:1336109180
Name:KETELAAR, MATTHEW A (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:KETELAAR
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 1:1970 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2710
Mailing Address - Country:US
Mailing Address - Phone:563-359-3949
Mailing Address - Fax:
Practice Address - Street 1:1970 E 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2710
Practice Address - Country:US
Practice Address - Phone:563-359-3949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA280072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300034141OtherRR MDC RGPCSC
IA5096792Medicaid
IA2096792Medicaid
300132302OtherRR MDC RGIC LLC
32281OtherBCBS IA RGPCSC
06050OtherBCBS IA RGIC LLC
IA2096792Medicaid