Provider Demographics
NPI:1700308095
Name:SUKOVATY, KELSEY MAE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:MAE
Last Name:SUKOVATY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3735 RAVENWOOD CIR APT 10
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5521
Mailing Address - Country:US
Mailing Address - Phone:515-370-3321
Mailing Address - Fax:
Practice Address - Street 1:3421 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5401
Practice Address - Country:US
Practice Address - Phone:319-272-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-09
Last Update Date:2017-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088135213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery