Healthcare Provider Details

I. General information

NPI: 1902846025
Provider Name (Legal Business Name): PATRICIA J CHUDOMELKA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11819 MIRACLE HILLS DR SUITE 105
OMAHA NE
68154-4428
US

IV. Provider business mailing address

PO BOX 30029
OMAHA NE
68103-1129
US

V. Phone/Fax

Practice location:
  • Phone: 402-978-5156
  • Fax: 402-341-3616
Mailing address:
  • Phone: 402-978-5156
  • Fax: 402-341-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number20620
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: