Healthcare Provider Details

I. General information

NPI: 1578140505
Provider Name (Legal Business Name): ADAM DZIACKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 PINE LAKE RD STE 210
LINCOLN NE
68516-5497
US

IV. Provider business mailing address

3901 PINE LAKE RD STE 210
LINCOLN NE
68516-5497
US

V. Phone/Fax

Practice location:
  • Phone: 402-488-7337
  • Fax: 402-488-7338
Mailing address:
  • Phone: 402-488-7337
  • Fax: 402-488-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36199
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: