Basic Information
| Provider Information | |||||||||
| NPI: | 1023236213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODEGAARD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 642117 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681648117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023986248 | ||||||||
| FaxNumber: | 4028298513 | ||||||||
| Practice Location | |||||||||
| Address1: | 7710 MERCY RD | ||||||||
| Address2: | SUITE 426 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681242372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027173636 | ||||||||
| FaxNumber: | 4027175050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 02/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5030 | NE | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 25123 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | BO8875734 | 01 | NE | DEA NUMBER | OTHER |