Provider Demographics
NPI:1679978084
Name:SODUSTA, DOMERLIN
Entity Type:Individual
Prefix:
First Name:DOMERLIN
Middle Name:
Last Name:SODUSTA
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 1:4905 S 107TH AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-1965
Mailing Address - Country:US
Mailing Address - Phone:402-968-1643
Mailing Address - Fax:
Practice Address - Street 1:4905 S 107TH AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-1965
Practice Address - Country:US
Practice Address - Phone:402-968-1643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10024973200Medicaid
NE4684730001Medicare UPIN