Healthcare Provider Details

I. General information

NPI: 1528060860
Provider Name (Legal Business Name): CAROL ANN DRAKE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 DODGE ST STE 143
OMAHA NE
68114-4100
US

IV. Provider business mailing address

8111 DODGE ST STE 143
OMAHA NE
68114-4100
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-5980
  • Fax: 402-354-5973
Mailing address:
  • Phone: 402-354-5980
  • Fax: 402-354-5973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number16274
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: