Healthcare Provider Details

I. General information

NPI: 1700530250
Provider Name (Legal Business Name): INFECTIOUS DISEASE PROVIDERS OF NEVADA LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W HORIZON RIDGE PKWY STE 100
HENDERSON NV
89052-5014
US

IV. Provider business mailing address

2900 W HORIZON RIDGE PKWY STE 100
HENDERSON NV
89052-5014
US

V. Phone/Fax

Practice location:
  • Phone: 702-307-5522
  • Fax: 702-991-7258
Mailing address:
  • Phone: 702-307-5522
  • Fax: 702-991-7258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: TODD RADIVAN
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 702-307-5522