MEDICARE: VAISHALI SUBHASH PHATAK PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist
2	103T00000X	Psychologist	939	NE
3	103G00000X	Clinical Neuropsychologist	939	NE

General Provider Information

NPI Number	:	1306965769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VAISHALI SUBHASH PHATAK PHD

Provider Business Mailing Address
First Line	:	988102 NEBRASKA MEDICAL CTR
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68198-8102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4242 FARNAM ST STE 550
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68131-2813
Country	:	US
Telephone Number	:	402-559-8600
Fax Number	:	402-559-5010

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	10/11/2017

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