Healthcare Provider Details

I. General information

NPI: 1629901137
Provider Name (Legal Business Name): RICHARD SHAWN WITTROCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 N 60TH ST BLDG C
OMAHA NE
68104-3402
US

IV. Provider business mailing address

3300 N 60TH ST BLDG C
OMAHA NE
68104-3402
US

V. Phone/Fax

Practice location:
  • Phone: 402-553-3000
  • Fax:
Mailing address:
  • Phone: 402-553-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCPSS-530
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: