Provider Demographics
NPI:1710923800
Name:VAN DE WATER, DONALD T (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:T
Last Name:VAN DE WATER
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:PO BOX 4460
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104
Mailing Address - Country:US
Mailing Address - Phone:866-491-5807
Mailing Address - Fax:913-491-0411
Practice Address - Street 1:800 MERCY DR
Practice Address - Street 2:ALEGENT MERCY HOSPITAL DEPT OF RADIOLOGY
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-3128
Practice Address - Country:US
Practice Address - Phone:712-328-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE185762085R0202X
IA213182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3537282Medicaid
IA5537282Medicaid
AV9724039OtherIA CONTROLLED SUBSTANCE
IA0537282Medicaid
24705OtherMIDLANDS
IA4537282Medicaid
IA1310532Medicaid
1600329OtherUHC SHARE ALLIANCE
03103OtherNEBRASKA BCBS
19065OtherIOWA BCBS
1600507OtherUHC SHARE ALLIANCE
1600507OtherUHC SHARE ALLIANCE
NE272832Medicare PIN
AV9724039OtherIA CONTROLLED SUBSTANCE
IA3537282Medicaid
IA0537282Medicaid
1600329OtherUHC SHARE ALLIANCE
IA4537282Medicaid
IA5537282Medicaid