Provider Demographics
NPI:1336243542
Name:LIUDAHL, KEVIN JAY (MD)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAY
Last Name:LIUDAHL
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 1:2730 PIERCE ST
Mailing Address - Street 2:STE 300
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-3765
Mailing Address - Country:US
Mailing Address - Phone:712-224-8677
Mailing Address - Fax:712-277-1662
Practice Address - Street 1:2800 PIERCE ST
Practice Address - Street 2:STE 101
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104
Practice Address - Country:US
Practice Address - Phone:712-224-8677
Practice Address - Fax:712-277-1662
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25978207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00784447OtherMEDICARE RR
IAIB1592001Medicare PIN