Provider Demographics
NPI:1972588119
Name:WALTKE, EUGENE A (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:A
Last Name:WALTKE
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 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:515 N 162ND AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2539
Practice Address - Country:US
Practice Address - Phone:402-393-6624
Practice Address - Fax:402-393-6635
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE146222086S0129X
IA269812086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025724800Medicaid
IA1972588119Medicaid
NE10026135100Medicaid
NE099099136Medicare PIN
NE10026135100Medicaid
IA075120005Medicare PIN