MEDICARE: DR. GARY MAX DESHAZO DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083P0901X	Public Health & General Preventive Medicine Physician	380	NV
2	261QC1500X	Community Health Clinic/Center	380	NV
3	207Q00000X	Family Medicine Physician	380	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CC4619	OTHER	NV	BLUE CROSS PIN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568512101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY MAX DESHAZO DO

Provider Business Mailing Address
First Line	:	2901 N TENAYA WAY STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1404
Country	:	US
Telephone Number	:	702-870-8852
Fax Number	:	702-870-8914

Provider Business Practice Location Address
First Line	:	2901 N TENAYA WAY STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1404
Country	:	US
Telephone Number	:	702-870-8852
Fax Number	:	702-870-8914

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	02/17/2022

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Directions to “ DR. GARY MAX DESHAZO DO” Practice Location

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