Provider Demographics
NPI:1831194307
Name:HUETTMAN, PACKY A JR (DO)
Entity type:Individual
Prefix:
First Name:PACKY
Middle Name:A
Last Name:HUETTMAN
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3200 WEST KIMBERLY ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806
Mailing Address - Country:US
Mailing Address - Phone:563-355-9191
Mailing Address - Fax:563-355-3419
Practice Address - Street 1:3200 WEST KIMBERLY ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806
Practice Address - Country:US
Practice Address - Phone:563-355-9191
Practice Address - Fax:563-355-3419
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA03132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2167544Medicaid
67701OtherIOWA HEALTH SOLUTIONS
4796890008OtherDMERC
066152OtherHEALTH ALLIANCE
30409OtherWELLMARK BC/BS
IA01D2OtherJOHN DEERE HEALTH PLAN
G65457Medicare UPIN
I7546Medicare PIN