Provider Demographics
NPI:1912074667
Name:SELENKE, GREGORY ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:ALAN
Last Name:SELENKE
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 1:113 CARMELA ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:IA
Mailing Address - Zip Code:50643-2170
Mailing Address - Country:US
Mailing Address - Phone:319-988-4672
Mailing Address - Fax:
Practice Address - Street 1:421 MAIN ST
Practice Address - Street 2:
Practice Address - City:REINBECK
Practice Address - State:IA
Practice Address - Zip Code:50669-1049
Practice Address - Country:US
Practice Address - Phone:319-788-5555
Practice Address - Fax:319-788-5551
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAG16030Medicare UPIN
IAI11472Medicare ID - Type Unspecified