MEDICARE: ETHAN MILTON CRUVANT MD

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	208D00000X	General Practice Physician	5854	NV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110227382	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	880344806A002	OTHER		TRIWEST

General Provider Information

NPI Number	:	1740287192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN MILTON CRUVANT MD

Provider Business Mailing Address
First Line	:	8205 W. WARM SPRINGS RD.
Second Line	:	SUITE 110
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-3612
Country	:	US
Telephone Number	:	702-735-8734
Fax Number	:	702-735-2726

Provider Business Practice Location Address
First Line	:	8205 W. WARM SPRINGS RD.
Second Line	:	SUITE 110
City	:	LAS VEGAS
State	:	NV
Zip	:	89113
Country	:	US
Telephone Number	:	702-735-8734
Fax Number	:	702-735-2726

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

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	06/14/2011

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Directions to “ ETHAN MILTON CRUVANT MD” Practice Location

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