1679576722 NPI number — DAVID A WIEBE M.D.

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	WIEBE
Provider First Name	:	DAVID
Provider Middle Name	:	A
Provider Name Prefix Text	:
Provider Name Suffix Text	:
Provider Credential Text	:	M.D.
Provider Gender Code	:	M

Provider Other Organization Name	:
Provider Other Organization Name Type Code	:
Provider Other Last Name	:
Provider Other First Name	:
Provider Other Middle Name	:
Provider Other Name Prefix Text	:
Provider Other Name Suffix Text	:
Provider Other Credential Text	:
Provider Other Last Name Type Code	:

NPI Number	:	1679576722
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
NPI Reactivation Date	:

Provider First Line Business Mailing Address	:	PO BOX 2168
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	KEARNEY
Provider Business Mailing Address State Name	:	NE
Provider Business Mailing Address Postal Code	:	688482168
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	3088652512
Provider Business Mailing Address Fax Number	:	3088652506

Provider First Line Business Practice Location Address	:	3500 CENTRAL AVE
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	KEARNEY
Provider Business Practice Location Address State Name	:	NE
Provider Business Practice Location Address Postal Code	:	688472944
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	3088652512
Provider Business Practice Location Address Fax Number	:	3088652506
Provider Enumeration Date	:	05/23/2005

Authorized Official Last Name	:
Authorized Official First Name	:
Authorized Official Middle Name	:
Authorized Official Title or Position	:
Authorized Official Telephone Number	:

• Taxonomy code: 207X00000X , with the licence number:  12637 , registered in the state of NE .

• Identifier: 46969 . This is a "BCBS" identifier , issued by the state of ( KS ) . This identifiers is of the category "".
• Identifier: 046969WI , issued by the state of ( KS ) . This identifiers is of the category "".
• Identifier: 645540 . This is a "FIRSTGUARD" identifier , issued by the state of ( KS ) . This identifiers is of the category "".
• Identifier: 1553 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "".
• Identifier: 93420WI , issued by the state of ( NE ) . This identifiers is of the category "".
• Identifier: B67599 . This identifiers is of the category "".