Provider Demographics
NPI:1033158084
Name:CAVERZAGIE, KELLY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JOHN
Last Name:CAVERZAGIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-595-3939
Mailing Address - Fax:402-595-3898
Practice Address - Street 1:988102 NEBRASKA MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-8102
Practice Address - Country:US
Practice Address - Phone:402-595-3939
Practice Address - Fax:402-595-3898
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426638207R00000X
NE22784207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101537515Medicaid
PA098821Medicare ID - Type Unspecified
PA101537515Medicaid