Provider Demographics
NPI:1851394738
Name:SEXTRO, PHILIP B (DPM)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:B
Last Name:SEXTRO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 DIERS AVE
Mailing Address - Street 2:PO BOX 5020
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5020
Mailing Address - Country:US
Mailing Address - Phone:308-381-0404
Mailing Address - Fax:308-381-0408
Practice Address - Street 1:620 DIERS AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68802-5020
Practice Address - Country:US
Practice Address - Phone:308-381-0404
Practice Address - Fax:308-381-0408
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE135213ES0103X
NE213E00000X213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE02549OtherBLUE CROSS BLUE SHIELD
NE0152470001OtherDMERC CIGNA
NE47062497913Medicaid
NE280175OtherMEDICARE
NE470624949OtherCHAMPUS
NE480021804OtherRAILROAD MEDICARE
NE0152470001OtherCIGNA
NE47062497913Medicaid