Provider Demographics
NPI:1255364568
Name:DETHLEFS, HENRY JOHN (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:JOHN
Last Name:DETHLEFS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4920 S 30TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1590
Mailing Address - Country:US
Mailing Address - Phone:402-734-4110
Mailing Address - Fax:402-991-5564
Practice Address - Street 1:4920 S 30TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1590
Practice Address - Country:US
Practice Address - Phone:402-734-4110
Practice Address - Fax:402-991-5564
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE19813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEG16698Medicare UPIN