Provider Demographics
NPI:1780689083
Name:NUTT, ROGER WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WAYNE
Last Name:NUTT
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 1:710 S 13TH ST
Mailing Address - Street 2:STE1200
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-5792
Mailing Address - Country:US
Mailing Address - Phone:402-370-4570
Mailing Address - Fax:
Practice Address - Street 1:710 S 13TH ST
Practice Address - Street 2:STE1200
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-5792
Practice Address - Country:US
Practice Address - Phone:402-370-4570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2010-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD25507Medicare UPIN
AZ86-0706406Medicare ID - Type Unspecified