Provider Demographics
NPI:1073684239
Name:MONTY R. SELLON M.D.
Entity Type:Organization
Organization Name:MONTY R. SELLON M.D.
Other - Org Name:MONTY SELLON M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:VASA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-753-6002
Mailing Address - Street 1:350 W 23RD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2592
Mailing Address - Country:US
Mailing Address - Phone:402-721-5727
Mailing Address - Fax:402-753-6096
Practice Address - Street 1:350 W 23RD ST
Practice Address - Street 2:SUITE C
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2592
Practice Address - Country:US
Practice Address - Phone:402-721-5727
Practice Address - Fax:402-753-6096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========OtherALL OTHER INSURANCE COMPA
NE=========01Medicaid
NE=========OtherALL OTHER INSURANCE COMPA