Healthcare Provider Details

I. General information

NPI: 1619165289
Provider Name (Legal Business Name): REIICHI IIZUKA, M.D. CHTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 W CHARLESTON BLVD STE 150
LAS VEGAS NV
89102-1966
US

IV. Provider business mailing address

3010 W CHARLESTON BLVD STE 150
LAS VEGAS NV
89102-1966
US

V. Phone/Fax

Practice location:
  • Phone: 702-878-0070
  • Fax: 702-818-1930
Mailing address:
  • Phone: 702-878-0070
  • Fax: 702-818-1930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2426
License Number StateNV

VIII. Authorized Official

Name: DR. REIICHI IIZUKA
Title or Position: MD
Credential:
Phone: 702-878-0070