Provider Demographics
NPI:1194702597
Name:DIEDRICHSEN, PETER E (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:DIEDRICHSEN
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 1275
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68602-1681
Mailing Address - Country:US
Mailing Address - Phone:402-563-3686
Mailing Address - Fax:402-563-3084
Practice Address - Street 1:3772 43RD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-1681
Practice Address - Country:US
Practice Address - Phone:402-563-3686
Practice Address - Fax:402-564-1797
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE14980207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47082635813Medicaid
NE01493OtherBLUE CROSS BLUE SHIELD
NE01493OtherBLUE CROSS BLUE SHIELD
NE47082635813Medicaid