Healthcare Provider Details

I. General information

NPI: 1043290406
Provider Name (Legal Business Name): OMAHA VASCULAR SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 DODGE ST SUITE 220
OMAHA NE
68114-4129
US

IV. Provider business mailing address

8111 DODGE ST SUITE 220
OMAHA NE
68114-4129
US

V. Phone/Fax

Practice location:
  • Phone: 402-393-6624
  • Fax: 402-393-6635
Mailing address:
  • Phone: 402-393-6624
  • Fax: 402-393-6635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. EUGENE A. WALTKE
Title or Position: PRESIDENT
Credential: MD
Phone: 402-393-6624