Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | NE134 | NE |
Y | 222Z00000X | Podiatrist | NE134 | NE |
NPI | 1013934074 |
---|---|
Provider Name | Dr. Wayne V Videtich |
First Address | Lincoln, NE 68502-3252 |
Second Address | Lincoln, NE 68502-3252 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2006 |
Last Update Date | 16/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2545 | BLUE CROSS/BLUE SHIELD (01) | NE |
47061112100 | (05) | NE |
6800630 | (05) | SD |
NE134 | MUTUAL OF OMAHA (01) | NE |
T40097 | (02) | NE |