Provider Demographics
NPI:1720080237
Name:MIEDEMA, DOUGLAS JAE (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JAE
Last Name:MIEDEMA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 9TH AVE N
Mailing Address - Street 2:P.O. BOX 277
Mailing Address - City:SIBLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51249-1012
Mailing Address - Country:US
Mailing Address - Phone:712-754-3658
Mailing Address - Fax:712-754-2634
Practice Address - Street 1:600 9TH AVE N
Practice Address - Street 2:
Practice Address - City:SIBLEY
Practice Address - State:IA
Practice Address - Zip Code:51249-1012
Practice Address - Country:US
Practice Address - Phone:712-754-3658
Practice Address - Fax:712-754-2634
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN537072800Medicaid
IA2049429Medicaid
IA167177OtherHOME HEALTH MEDICARE
MN115478OtherUCARE
MN115478OtherUCARE
MN537072800Medicaid