Healthcare Provider Details

I. General information

NPI: 1922268234
Provider Name (Legal Business Name): WAYNE V VIDETICH DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 SOUTH ST
LINCOLN NE
68502-3252
US

IV. Provider business mailing address

2710 SOUTH ST
LINCOLN NE
68502-3252
US

V. Phone/Fax

Practice location:
  • Phone: 402-477-3200
  • Fax: 402-477-3561
Mailing address:
  • Phone: 402-477-3200
  • Fax: 402-477-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License NumberNE134
License Number StateNE

VIII. Authorized Official

Name: DR. WAYNE V VIDETICH
Title or Position: PRESIDENT
Credential: DPM
Phone: 402-477-3200