Healthcare Provider Details

I. General information

NPI: 1215159306
Provider Name (Legal Business Name): SANGHAMITRA BASU MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 FIRE MESA ST SUITE 110
LAS VEGAS NV
89128-9009
US

IV. Provider business mailing address

6955 N. DURANGO DRIVE STE #1115-301
LAS VEGAS NV
89149-4411
US

V. Phone/Fax

Practice location:
  • Phone: 702-362-7246
  • Fax: 702-362-7272
Mailing address:
  • Phone: 702-362-7246
  • Fax: 702-362-7272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SANGHAMITRA BASU
Title or Position: PRINCIPAL
Credential: M.D.
Phone: 702-362-7246