Healthcare Provider Details

I. General information

NPI: 1508185406
Provider Name (Legal Business Name): LAXMI SUDARSHAN IYER M.D.,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BROCKTON AVE STE 107
RIVERSIDE CA
92501-4006
US

IV. Provider business mailing address

6827 W TROPICANA AVE STE 110
LAS VEGAS NV
89103-4920
US

V. Phone/Fax

Practice location:
  • Phone: 951-276-2760
  • Fax: 951-276-2960
Mailing address:
  • Phone: 800-881-4226
  • Fax: 702-960-4190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberA165408
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA165408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: