Provider Demographics
NPI:1972528560
Name:STURTEVANT, DWAYNE F (OD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:F
Last Name:STURTEVANT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 COUNTY ROAD 30
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:NE
Mailing Address - Zip Code:68070-4120
Mailing Address - Country:US
Mailing Address - Phone:402-642-5058
Mailing Address - Fax:402-642-5058
Practice Address - Street 1:513 S 13TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-2813
Practice Address - Country:US
Practice Address - Phone:402-344-0219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1511152W00000X
NE0754152W00000X
NE754152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0134080Medicaid
IA0134080Medicaid
T01475Medicare UPIN
IA51808Medicare ID - Type Unspecified