Provider Demographics
NPI:1184702409
Name:DEAVER, LENNIE J (MD)
Entity type:Individual
Prefix:
First Name:LENNIE
Middle Name:J
Last Name:DEAVER
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 488
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:NE
Mailing Address - Zip Code:69022
Mailing Address - Country:US
Mailing Address - Phone:308-697-1526
Mailing Address - Fax:308-697-3278
Practice Address - Street 1:309 NELSON ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:NE
Practice Address - Zip Code:69022-3592
Practice Address - Country:US
Practice Address - Phone:308-697-1419
Practice Address - Fax:308-697-3278
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENE16867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE16867Medicaid
NE096657Medicare PIN
A02816Medicare UPIN