Provider Demographics
NPI:1528048451
Name:VANRAALTE, BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:VANRAALTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4334 E 53RD ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3039
Mailing Address - Country:US
Mailing Address - Phone:563-322-8877
Mailing Address - Fax:563-322-8375
Practice Address - Street 1:4334 E 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3039
Practice Address - Country:US
Practice Address - Phone:563-322-8877
Practice Address - Fax:563-322-8375
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA29526174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA0113241Medicaid
IA49703Medicare PIN
IAIA0113241Medicaid