Healthcare Provider Details

I. General information

NPI: 1407951700
Provider Name (Legal Business Name): JASON MICHAEL BELLAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 BOX CANYON DR
LAS VEGAS NV
89128-0450
US

IV. Provider business mailing address

2625 BOX CANYON DR
LAS VEGAS NV
89128-0450
US

V. Phone/Fax

Practice location:
  • Phone: 702-360-6100
  • Fax: 702-360-8096
Mailing address:
  • Phone: 702-360-6100
  • Fax: 702-360-8096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number48534
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number48534
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number21151
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: