Healthcare Provider Details

I. General information

NPI: 1962200907
Provider Name (Legal Business Name): JOHNNY B WALKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11340 BLONDO ST
OMAHA NE
68164-3815
US

IV. Provider business mailing address

6258 S 36TH AVE
OMAHA NE
68107-3824
US

V. Phone/Fax

Practice location:
  • Phone: 402-889-5686
  • Fax:
Mailing address:
  • Phone: 402-718-6359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: