Provider Demographics
NPI:1952492845
Name:ICHTERTZ, DOLF R (MD)
Entity Type:Individual
Prefix:DR
First Name:DOLF
Middle Name:R
Last Name:ICHTERTZ
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 1:716 N ALPHA ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4318
Mailing Address - Country:US
Mailing Address - Phone:308-389-3312
Mailing Address - Fax:308-389-3390
Practice Address - Street 1:716 N ALPHA ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4318
Practice Address - Country:US
Practice Address - Phone:308-389-3312
Practice Address - Fax:308-389-3390
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE218344310207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE07250OtherBCBS PROVIDER ID
NE47082696900Medicaid
NE200036906OtherRR MEDICARE PROVIDER ID
NE47082696900Medicaid
NEC99679Medicare UPIN