Provider Demographics
NPI:1669530630
Name:DITTRICK, GEORGE WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WILLIAM
Last Name:DITTRICK
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 1:8111 DODGE ST
Practice Address - Street 2:STE. 263
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4129
Practice Address - Country:US
Practice Address - Phone:402-354-8163
Practice Address - Fax:402-354-2416
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1031802086X0206X, 207P00000X
NE252642086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1669530630Medicaid
NE47068731707Medicaid
NE10025868900Medicaid
NE10025868900Medicaid