Healthcare Provider Details

I. General information

NPI: 1669530630
Provider Name (Legal Business Name): GEORGE WILLIAM DITTRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8111 DODGE ST STE. 263
OMAHA NE
68114-4129
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-8163
  • Fax: 402-354-2416
Mailing address:
  • Phone: 402-354-2100
  • Fax: 402-354-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberME103180
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME103180
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number25264
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: