Healthcare Provider Details

I. General information

NPI: 1184309874
Provider Name (Legal Business Name): PHILIP GEORGE FEDOR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10624 S EASTERN AVE # A-955
HENDERSON NV
89052-2982
US

IV. Provider business mailing address

10624 S EASTERN AVE # A-955
HENDERSON NV
89052-2982
US

V. Phone/Fax

Practice location:
  • Phone: 702-407-7700
  • Fax: 702-407-7016
Mailing address:
  • Phone: 702-407-7700
  • Fax: 702-407-7016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO4060
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: