Healthcare Provider Details

I. General information

NPI: 1760683585
Provider Name (Legal Business Name): JESSE BARONDEAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 11/28/2023
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8552 CASS ST
OMAHA NE
68114-3567
US

IV. Provider business mailing address

PO BOX 247037
OMAHA NE
68124-7037
US

V. Phone/Fax

Practice location:
  • Phone: 402-955-4140
  • Fax:
Mailing address:
  • Phone: 402-955-6935
  • Fax: 402-955-6931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number24022
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberSD9881
License Number StateSD
# 3
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number24022
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: