1750643193 NPI number — DR. DARRICK PETERS DO

Table of content: DR. DARRICK PETERS DO (NPI 1750643193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750643193 NPI number — DR. DARRICK PETERS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERS
Provider First Name:
DARRICK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1750643193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3755
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68103-0755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-354-2100
Provider Business Mailing Address Fax Number:
402-354-2155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
717 N 190TH PLZ
Provider Second Line Business Practice Location Address:
STE 1100
Provider Business Practice Location Address City Name:
ELKHORN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68022-3913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-815-1700
Provider Business Practice Location Address Fax Number:
402-815-1959
Provider Enumeration Date:
06/12/2012

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: 207V00000X , with the licence number:  BP10044115 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 1429 , 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: 10026480100 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47068731799 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10026301600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1750643193 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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