Provider Demographics
NPI:1063525277
Name:JOHN DEERE MEDICAL GROUP OF WATERLOO, PC
Entity type:Organization
Organization Name:JOHN DEERE MEDICAL GROUP OF WATERLOO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOEKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:319-274-1016
Mailing Address - Street 1:1015 S HACKETT RD
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-3500
Mailing Address - Country:US
Mailing Address - Phone:319-274-1000
Mailing Address - Fax:319-292-6526
Practice Address - Street 1:1015 S HACKETT RD
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-3500
Practice Address - Country:US
Practice Address - Phone:319-274-1000
Practice Address - Fax:319-292-6526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01585174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1097592Medicaid
IAA02912Medicare UPIN
IA58596Medicare ID - Type Unspecified