Healthcare Provider Details

I. General information

NPI: 1144582966
Provider Name (Legal Business Name): MIMI MARELLA KURIAKOSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARELLA KURIAKOSE HUDKINS MD

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6070 S RAINBOW BLVD UNIT 10
LAS VEGAS NV
89118-2503
US

IV. Provider business mailing address

6070 S RAINBOW BLVD UNIT 10
LAS VEGAS NV
89118-2501
US

V. Phone/Fax

Practice location:
  • Phone: 702-420-7222
  • Fax: 702-331-6018
Mailing address:
  • Phone: 702-420-7222
  • Fax: 702-331-6018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number16076
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number16076
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: