Provider Demographics
NPI:1649573676
Name:ANTCZAK, FRED
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:ANTCZAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17931 PIERCE PLZ
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2654
Mailing Address - Country:US
Mailing Address - Phone:402-933-1393
Mailing Address - Fax:402-933-1899
Practice Address - Street 1:17931 PIERCE PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68130-2654
Practice Address - Country:US
Practice Address - Phone:402-933-1393
Practice Address - Fax:402-933-1899
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2255222Z00000X, 225000000X
VA0675224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter