Healthcare Provider Details

I. General information

NPI: 1053407064
Provider Name (Legal Business Name): OMAHA NEPHROLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 N 102ND CT STE 200
OMAHA NE
68114-2194
US

IV. Provider business mailing address

1111 N 102ND CT STE 200
OMAHA NE
68114-2194
US

V. Phone/Fax

Practice location:
  • Phone: 402-502-2747
  • Fax: 402-502-2387
Mailing address:
  • Phone: 402-502-2747
  • Fax: 402-502-2387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID C GOLDNER
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 402-502-2747