Provider Demographics
NPI:1871589754
Name:KLISE, KURT J (MD)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:J
Last Name:KLISE
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:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-300-3900
Mailing Address - Fax:515-300-3901
Practice Address - Street 1:250 SW BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-4900
Practice Address - Country:US
Practice Address - Phone:515-300-3900
Practice Address - Fax:515-300-3901
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA080195357OtherRR MEDICARE
IA3219469Medicaid
A02520Medicare UPIN
IA3219469Medicaid