Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | 036-100466 | IL |
Y | 207K00000X | Allergist & Immunologist | 32545 | IA |
N | 208000000X | Pediatrician | 036-100466 | IL |
N | 208000000X | Pediatrician | 32545 | IA |
NPI | 1003819624 |
---|---|
Provider Name | Felipe Coscolluela Javier III |
First Address | Waterloo, IA 50702-5634 |
Second Address | Waterloo, IA 50702-5634 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2005 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
203896410 | (05) | MO |
33628 | BLUE CROSS BLUE SHIELD (01) | |
421527584 | TRI-CARE GROUP NUMBER (01) | |
421527584003 | (05) | IL |
42152758408 | JOHN DEERE (01) | |
G83139 | (02) | |
O278374 | (05) | IA |