Basic Information
| Provider Information | |||||||||
| NPI: | 1003949918 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADULT & PEDIATRIC UROLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8577 | ||||||||
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| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681080577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023977989 | ||||||||
| FaxNumber: | 4023978703 | ||||||||
| Practice Location | |||||||||
| Address1: | 1213 GARFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | HARLAN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515372057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7127555161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DESOUZA | ||||||||
| AuthorizedOfficialFirstName: | EUCLID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4023977989 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.