Healthcare Provider Details

I. General information

NPI: 1073679940
Provider Name (Legal Business Name): HEIBEL DERMATOLOGY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 PRESERVE LN
LINCOLN NE
68516-4473
US

IV. Provider business mailing address

7701 PRESERVE LN
LINCOLN NE
68516-4473
US

V. Phone/Fax

Practice location:
  • Phone: 402-488-6969
  • Fax: 402-488-6911
Mailing address:
  • Phone: 402-488-6969
  • Fax: 402-488-6911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number18056
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number18056
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number18056
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number18056
License Number StateNE
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number18056
License Number StateNE
# 6
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number18056
License Number StateNE

VIII. Authorized Official

Name: MARK D HEIBEL
Title or Position: MD
Credential: MD
Phone: 402-488-6969