Basic Information
| Provider Information | |||||||||
| NPI: | 1063466217 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINJUM | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7239 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024899400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7121 STEPHANIE LN | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685165359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024203500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 10/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 20719 | NE | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100313450A | 05 | KS | MEDICAID | 7783110 | 05 | SD | MEDICAID | 32295 | 01 | NE | BLUE CROSS BLUE SHIELD | OTHER | 300086696 | 01 | NE | RR MEDICARE | OTHER | 0521021 | 05 | IA | MEDICAID |