Healthcare Provider Details

I. General information

NPI: 1720909062
Provider Name (Legal Business Name): MARIAN GISELLE FARFAN FONTALVO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12011 S 29TH AVE
BELLEVUE NE
68123-1467
US

IV. Provider business mailing address

12011 S 29TH AVE
BELLEVUE NE
68123-1467
US

V. Phone/Fax

Practice location:
  • Phone: 402-216-1318
  • Fax:
Mailing address:
  • Phone: 402-216-1318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: