Healthcare Provider Details

I. General information

NPI: 1467593715
Provider Name (Legal Business Name): MARK R. THIELE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 W LAKE MEAD PKWY
HENDERSON NV
89015-7015
US

IV. Provider business mailing address

6355 S BUFFALO DR FL 3
LAS VEGAS NV
89113-2133
US

V. Phone/Fax

Practice location:
  • Phone: 702-565-1007
  • Fax: 702-565-0836
Mailing address:
  • Phone: 702-216-3346
  • Fax: 702-671-6883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME104257
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20364
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: