Provider Demographics
NPI:1164486528
Name:DEWALD, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:DEWALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:D
Other - Last Name:DEWALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7601 PIONEERS BLVD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-4675
Mailing Address - Country:US
Mailing Address - Phone:402-484-6677
Mailing Address - Fax:402-484-4476
Practice Address - Street 1:7601 PIONEERS BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-4675
Practice Address - Country:US
Practice Address - Phone:402-484-6677
Practice Address - Fax:402-484-4476
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE197162085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078180813Medicaid
NENA1330010OtherSMI MEDICARE PIN
NE273366OtherAMI MEDICARE PIN
F59701Medicare UPIN
NENA1330010OtherSMI MEDICARE PIN