Healthcare Provider Details

I. General information

NPI: 1548219462
Provider Name (Legal Business Name): SAMUEL JAMES DETERMAN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17816 HOLMES CIR
OMAHA NE
68135-3406
US

IV. Provider business mailing address

17816 HOLMES CIR
OMAHA NE
68135-3406
US

V. Phone/Fax

Practice location:
  • Phone: 402-895-2583
  • Fax:
Mailing address:
  • Phone: 402-895-2583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number296
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: