Basic Information
| Provider Information | |||||||||
| NPI: | 1356387831 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADULT & PEDIATRIC UROLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8577 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681080577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023977989 | ||||||||
| FaxNumber: | 4023937554 | ||||||||
| Practice Location | |||||||||
| Address1: | 10707 PACIFIC ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681144762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023977989 | ||||||||
| FaxNumber: | 4023978703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 07/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | DESOUZA | ||||||||
| AuthorizedOfficialFirstName: | EUCLID | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| 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 |
ID Information
| ID | Type | State | Issuer | Description | 0424739 | 05 | IA | MEDICAID |