Healthcare Provider Details

I. General information

NPI: 1649729161
Provider Name (Legal Business Name): HOMAYON IRANINEZHAD DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N BUFFALO DR
LAS VEGAS NV
89145-0373
US

IV. Provider business mailing address

PO BOX 371086
LAS VEGAS NV
89137-1086
US

V. Phone/Fax

Practice location:
  • Phone: 702-623-3454
  • Fax: 702-666-0374
Mailing address:
  • Phone: 702-623-6454
  • Fax: 702-666-0374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberDO1453
License Number StateNV

VIII. Authorized Official

Name: XENETEIA AQUINO
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 702-818-9397