Provider Demographics
NPI:1902124175
Name:KETTMAN PRANGER FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:KETTMAN PRANGER FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:KETTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-236-7720
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-0658
Mailing Address - Country:US
Mailing Address - Phone:319-236-7720
Mailing Address - Fax:319-236-7739
Practice Address - Street 1:220 SOUTHBROOKE DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5802
Practice Address - Country:US
Practice Address - Phone:319-236-7720
Practice Address - Fax:319-236-7739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1838Medicare PIN