Provider Demographics
NPI:1013934074
Name:VIDETICH, WAYNE V (DPM)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:V
Last Name:VIDETICH
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 1:2710 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE134213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE2545OtherBLUE CROSS/BLUE SHIELD
NE47061112100Medicaid
SD6800630Medicaid
NENE134OtherMUTUAL OF OMAHA
NENE134OtherMUTUAL OF OMAHA
NE47061112100Medicaid
SD6800630Medicaid