Provider Demographics
NPI:1801832910
Name:JAKSHA, MATTHEW M (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:M
Last Name:JAKSHA
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 1:7500 MERCY RD
Practice Address - Street 2:ALEGENT BERGAN MERCY DEPT OF RADIOLOGY
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2319
Practice Address - Country:US
Practice Address - Phone:402-398-5890
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
NE214822085R0202X
IA336542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
20829OtherMIDLANDS
IA4223388Medicaid
NE03518OtherBCBS
IA1223388Medicaid
NE21482OtherNE LICENSE #
BJ6988907OtherIA CONTROLLED SUBSTANCE
IA22367OtherBCBS
IA0223388Medicaid
IA1571877Medicaid
33654OtherIA LICENSE #
IA0571877Medicaid
IA0571877Medicaid
BJ6988907OtherIA CONTROLLED SUBSTANCE
IA300113164Medicare PIN
H22542Medicare UPIN
33654OtherIA LICENSE #
IA22367OtherBCBS
IA1571877Medicaid
BJ5839610OtherDEA #