Healthcare Provider Details

I. General information

NPI: 1053686972
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BREAKTHROUGH WAY
LAS VEGAS NV
89135-3011
US

IV. Provider business mailing address

1 BREAKTHROUGH WAY
LAS VEGAS NV
89135-3011
US

V. Phone/Fax

Practice location:
  • Phone: 702-822-5433
  • Fax:
Mailing address:
  • Phone: 702-822-5433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number StateNV

VIII. Authorized Official

Name: MICKEY GOLDMAN
Title or Position: PRESIDENT/CEO
Credential: FACHE
Phone: 702-821-0005