Healthcare Provider Details

I. General information

NPI: 1972588119
Provider Name (Legal Business Name): EUGENE A. WALTKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N 162ND AVE SUITE 300
OMAHA NE
68118-2539
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 402-393-6624
  • Fax: 402-393-6635
Mailing address:
  • Phone: 402-354-2100
  • Fax: 402-354-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number14622
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number26981
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: