Healthcare Provider Details

I. General information

NPI: 1831182757
Provider Name (Legal Business Name): CLARK W ANTONSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 R ST
LINCOLN NE
68503-3723
US

IV. Provider business mailing address

4545 R ST
LINCOLN NE
68503-3723
US

V. Phone/Fax

Practice location:
  • Phone: 402-465-4545
  • Fax: 402-465-3621
Mailing address:
  • Phone: 402-465-4545
  • Fax: 402-465-3621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number17282
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number17282
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: