Healthcare Provider Details

I. General information

NPI: 1366444937
Provider Name (Legal Business Name): SAMUEL ANTONIO MUJICA TRENCHE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3265 ROSANNA ST
LAS VEGAS NV
89117-3137
US

IV. Provider business mailing address

3265 ROSANNA ST
LAS VEGAS NV
89117-3137
US

V. Phone/Fax

Practice location:
  • Phone: 702-205-1948
  • Fax: 702-876-9181
Mailing address:
  • Phone: 702-205-1948
  • Fax: 702-876-9181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5456
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: