1295748903 NPI number — DR. LARRY E MALICKY OD FAAO

Table of content: DR. LARRY E MALICKY OD FAAO (NPI 1295748903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295748903 NPI number — DR. LARRY E MALICKY OD FAAO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALICKY
Provider First Name:
LARRY
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD FAAO
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1295748903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
566 S QUAIL LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68601-6308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-908-4787
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
566 S QUAIL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68601-6308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-561-0545
Provider Business Practice Location Address Fax Number:
402-564-0078
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  801 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 47055862700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: N001920 . This is a "CHAMPUS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 06731 . This is a "BC" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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