Healthcare Provider Details

I. General information

NPI: 1922306497
Provider Name (Legal Business Name): HERAGANAHALLY NAGEGOWDA SUNDAR RAJ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: H.N. SUNDAR RAJ MD

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 N DECATUR BLVD STE 5
LAS VEGAS NV
89108-2497
US

IV. Provider business mailing address

6255 SHARLANDS AVE
RENO NV
89523-2882
US

V. Phone/Fax

Practice location:
  • Phone: 702-785-3005
  • Fax:
Mailing address:
  • Phone: 775-770-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4121
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number4121
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD 4121
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: