=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003080938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC OPHTHALMOLOGY ASSOCIATES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2008
-----------------------------------------------------
Last Update Date | 08/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 N 98TH ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68114-2368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-399-9400
-----------------------------------------------------
Fax | 402-399-8170
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 N 98TH ST
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68114-2368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-399-9400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING & CONTRACTING MANAGER
-----------------------------------------------------
Name | MR. DYLAN M STOFFER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 402-399-9400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------