Provider Demographics
NPI:1801096599
Name:DEJONG, PAUL W (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:DEJONG
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 1:1202 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK VALLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51247-1420
Mailing Address - Country:US
Mailing Address - Phone:712-476-8100
Mailing Address - Fax:712-476-8190
Practice Address - Street 1:1202 21ST AVE
Practice Address - Street 2:
Practice Address - City:ROCK VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51247-1420
Practice Address - Country:US
Practice Address - Phone:712-476-8100
Practice Address - Fax:712-476-8190
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7592207Q00000X
IAMD-37603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP00753617Medicare PIN
SDS103547Medicare PIN