Provider Demographics
NPI:1881927341
Name:DR ROY LIDTKE PLC
Entity type:Organization
Organization Name:DR ROY LIDTKE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIDTKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-929-5572
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50301-0280
Mailing Address - Country:US
Mailing Address - Phone:516-883-7100
Mailing Address - Fax:516-883-7474
Practice Address - Street 1:1026 A AVE NE
Practice Address - Street 2:SUITE 5000
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5036
Practice Address - Country:US
Practice Address - Phone:319-929-5572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00555213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty