Provider Demographics
NPI:1366941189
Name:NOACK, TODD
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:NOACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 6TH ST
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-1722
Mailing Address - Country:US
Mailing Address - Phone:563-726-3244
Mailing Address - Fax:
Practice Address - Street 1:222 12TH ST
Practice Address - Street 2:
Practice Address - City:DE WITT
Practice Address - State:IA
Practice Address - Zip Code:52742-1116
Practice Address - Country:US
Practice Address - Phone:563-726-3244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAPR16012175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA82-0730805Medicaid