Provider Demographics
NPI:1992796197
Name:PUDENZ, DAPHNE ANN (MD)
Entity type:Individual
Prefix:DR
First Name:DAPHNE
Middle Name:ANN
Last Name:PUDENZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DAPHNE
Other - Middle Name:ANN
Other - Last Name:GONSALVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:405 S CLARK ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3065
Mailing Address - Country:US
Mailing Address - Phone:712-792-1500
Mailing Address - Fax:712-792-1407
Practice Address - Street 1:405 S CLARK ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3065
Practice Address - Country:US
Practice Address - Phone:712-792-1500
Practice Address - Fax:712-792-1407
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32844207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2186528Medicaid
IAG96020Medicare UPIN
IA2186528Medicaid