Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 2255 | VA |
Y | 222Z00000X | Podiatrist | 2255 | VA |
N | 225000000X | Orthotic Fitter | 2255 | VA |
NPI | 1649573676 |
---|---|
Provider Name | Fred Antczak |
First Address | Omaha, NE 68130-2654 |
Second Address | Omaha, NE 68130-2654 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2010 |
Last Update Date | 14/12/2010 |