Provider Demographics
NPI:1962965681
Name:MONHOLLON, ETHAN DANIEL
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:DANIEL
Last Name:MONHOLLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 S LINN ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-1802
Mailing Address - Country:US
Mailing Address - Phone:319-338-9222
Mailing Address - Fax:319-338-7250
Practice Address - Street 1:701 10TH ST SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-1251
Practice Address - Country:US
Practice Address - Phone:319-398-6011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN63675207P00000X
390200000X
IAMD-49479207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program