Provider Demographics
NPI:1467446799
Name:DUFF, WALLACE E (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:E
Last Name:DUFF
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 1:11704 W CENTER RD STE 210
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4327
Mailing Address - Country:US
Mailing Address - Phone:402-393-1454
Mailing Address - Fax:402-393-3725
Practice Address - Street 1:11704 W CENTER RD STE 210
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4327
Practice Address - Country:US
Practice Address - Phone:402-393-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11860207Y00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE093562Medicare ID - Type Unspecified