Healthcare Provider Details

I. General information

NPI: 1255364568
Provider Name (Legal Business Name): HENRY JOHN DETHLEFS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 S 30TH ST SUITE 103
OMAHA NE
68107-1590
US

IV. Provider business mailing address

4920 S 30TH ST SUITE 103
OMAHA NE
68107-1590
US

V. Phone/Fax

Practice location:
  • Phone: 402-734-4110
  • Fax: 402-991-5564
Mailing address:
  • Phone: 402-734-4110
  • Fax: 402-991-5564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19813
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: