Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | A05887 | IA |
NPI | 1144249418 |
---|---|
Provider Name | Dr. Dennis E. Wolter |
First Address | Keokuk, IA 52632-4655 |
Second Address | Keokuk, IA 52632-4655 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2006 |
Last Update Date | 10/01/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
52935 | BC/BS (01) | IA |
615537 | TRIGON (01) | IA |
U57366 | (02) | IA |