Healthcare Provider Details

I. General information

NPI: 1699775684
Provider Name (Legal Business Name): MAHENDRA DEFONSEKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 W HORIZON RIDGE PKWY SUITE 105
HENDERSON NV
89052-2869
US

IV. Provider business mailing address

8010 W SAHARA AVE SUITE 235
LAS VEGAS NV
89117-7905
US

V. Phone/Fax

Practice location:
  • Phone: 702-565-3037
  • Fax:
Mailing address:
  • Phone: 702-256-3637
  • Fax: 702-256-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number3983
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: