Provider Demographics
NPI:1922268234
Name:WAYNE V VIDETICH DPM PC
Entity Type:Organization
Organization Name:WAYNE V VIDETICH DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:V
Authorized Official - Last Name:VIDETICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:402-477-3200
Mailing Address - Street 1:2710 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-3252
Mailing Address - Country:US
Mailing Address - Phone:402-477-3200
Mailing Address - Fax:402-477-3561
Practice Address - Street 1:2710 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3252
Practice Address - Country:US
Practice Address - Phone:402-477-3200
Practice Address - Fax:402-477-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE134261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE88434OtherCOVENTRY
NE2545OtherBLUE CROSS/BLUE SHIELD
NENE134OtherMUTUAL OF OMAHA
NENE134OtherMUTUAL OF OMAHA
NE2545OtherBLUE CROSS/BLUE SHIELD
NE88434OtherCOVENTRY
NE091218Medicare PIN