Healthcare Provider Details

I. General information

NPI: 1629207261
Provider Name (Legal Business Name): JEFFREY C WIENKE JR. DPM CWSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2009
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N 83RD ST
LINCOLN NE
68505-2094
US

IV. Provider business mailing address

1150 N 83RD ST
LINCOLN NE
68505-2094
US

V. Phone/Fax

Practice location:
  • Phone: 402-483-4485
  • Fax:
Mailing address:
  • Phone: 402-483-4485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number206
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000820
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number345
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: