Provider Demographics
NPI:1164520367
Name:WILCZEWSKI, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WILCZEWSKI
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 1:8401 W DODGE RD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3451
Mailing Address - Country:US
Mailing Address - Phone:402-955-6877
Mailing Address - Fax:402-955-6880
Practice Address - Street 1:16909 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68135-1521
Practice Address - Country:US
Practice Address - Phone:402-955-7575
Practice Address - Fax:402-955-7555
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20184208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068937239Medicaid
NE5000OtherMIDLANDS CHOICE
IA97572OtherBCBS
IA507509Medicaid
NE31391OtherBCBS