Provider Demographics
NPI:1487631818
Name:VETICK, RUSSELL M (OD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:M
Last Name:VETICK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N ST
Mailing Address - Street 2:
Mailing Address - City:NELIGH
Mailing Address - State:NE
Mailing Address - Zip Code:68756-1428
Mailing Address - Country:US
Mailing Address - Phone:402-887-4506
Mailing Address - Fax:402-887-5100
Practice Address - Street 1:304 N ST
Practice Address - Street 2:
Practice Address - City:NELIGH
Practice Address - State:NE
Practice Address - Zip Code:68756-1428
Practice Address - Country:US
Practice Address - Phone:402-887-4506
Practice Address - Fax:402-887-5100
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE36771OtherBLUE CROSS BLUE SHIELD
NE47082635802Medicaid
NE36771OtherBLUE CROSS BLUE SHIELD
NE272349Medicare ID - Type Unspecified