Healthcare Provider Details

I. General information

NPI: 1376342998
Provider Name (Legal Business Name): GARY GEORGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2025
Last Update Date: 03/08/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7110 F ST
OMAHA NE
68117-1014
US

IV. Provider business mailing address

2565 NEWPORT AVE
OMAHA NE
68112-3325
US

V. Phone/Fax

Practice location:
  • Phone: 712-328-2638
  • Fax:
Mailing address:
  • Phone: 402-658-6652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberH12145135
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: