Healthcare Provider Details

I. General information

NPI: 1104829563
Provider Name (Legal Business Name): GREGORY S SEXTRO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N DIERS AVE STE. 200
GRAND ISLAND NE
68803-4984
US

IV. Provider business mailing address

620 N DIERS AVE STE. 200
GRAND ISLAND NE
68803-4984
US

V. Phone/Fax

Practice location:
  • Phone: 308-384-5400
  • Fax: 308-384-5201
Mailing address:
  • Phone: 308-384-5400
  • Fax: 308-384-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number21854
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: