1790979672 NPI number — DR. GREGORY V MANN O.D.

Table of content: DR. GREGORY V MANN O.D. (NPI 1790979672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790979672 NPI number — DR. GREGORY V MANN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANN
Provider First Name:
GREGORY
Provider Middle Name:
V
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1790979672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 99
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TECUMSEH
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68450-0099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-335-2022
Provider Business Mailing Address Fax Number:
402-335-3168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 N 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TECUMSEH
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68450-2491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-335-2022
Provider Business Practice Location Address Fax Number:
402-335-3168
Provider Enumeration Date:
09/04/2007

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:  921 , 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: 47069546100 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: CSO141 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 2200006 . This is a "UNITEDHEALTHCARE PIN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 06766 . This is a "BCBS PIN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: GUS12D67 . This is a "MUTUAL OF OMAHA PIN" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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