Provider Demographics
NPI:1699786962
Name:KETCHAM, TIFFANY (DO)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:KETCHAM
Suffix:
Gender:F
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:PO BOX 424
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50302-0424
Mailing Address - Country:US
Mailing Address - Phone:515-875-9925
Mailing Address - Fax:515-875-9923
Practice Address - Street 1:825 NE GATEWAY DR STE 148
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-1307
Practice Address - Country:US
Practice Address - Phone:515-875-9607
Practice Address - Fax:515-875-9608
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0196063Medicaid
IAH09568Medicare UPIN
IA08558Medicare ID - Type Unspecified