Healthcare Provider Details

I. General information

NPI: 1851394738
Provider Name (Legal Business Name): PHILIP B SEXTRO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 DIERS AVE
GRAND ISLAND NE
68802-5020
US

IV. Provider business mailing address

620 DIERS AVE PO BOX 5020
GRAND ISLAND NE
68802-5020
US

V. Phone/Fax

Practice location:
  • Phone: 308-381-0404
  • Fax: 308-381-0408
Mailing address:
  • Phone: 308-381-0404
  • Fax: 308-381-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number135
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number213E00000X
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: