Healthcare Provider Details

I. General information

NPI: 1821595877
Provider Name (Legal Business Name): DIVA VITEARE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIVA VITEARE BOMGAARS MD

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 04/12/2026
Certification Date: 04/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W GRUENTHER RD
GRETNA NE
68028-4828
US

IV. Provider business mailing address

102 W GRUENTHER RD
GRETNA NE
68028-4828
US

V. Phone/Fax

Practice location:
  • Phone: 402-332-2772
  • Fax: 402-332-5446
Mailing address:
  • Phone: 402-332-2772
  • Fax: 402-332-5446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33607
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-48710
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: