Provider Demographics
NPI:1730172040
Name:ROZEBOOM, PAUL ANDREW (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:ANDREW
Last Name:ROZEBOOM
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 1:300 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-2355
Mailing Address - Country:US
Mailing Address - Phone:712-246-1230
Mailing Address - Fax:
Practice Address - Street 1:1 JACK FOSTER DR
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-4586
Practice Address - Country:US
Practice Address - Phone:712-246-7400
Practice Address - Fax:712-246-7334
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA321072080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB2716019Medicare Oscar/Certification
E12541Medicare UPIN