Healthcare Provider Details

I. General information

NPI: 1356596134
Provider Name (Legal Business Name): DR AJAY NELLUTLA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 S MARYLAND PKWY SUITE #100
LAS VEGAS NV
89109-2441
US

IV. Provider business mailing address

FILE # 1304-1801 W.OLYMPIC BLVD
PASADENA CA
91199-1304
US

V. Phone/Fax

Practice location:
  • Phone: 702-649-8009
  • Fax: 702-649-8049
Mailing address:
  • Phone: 702-938-0419
  • Fax: 702-939-6954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number10766
License Number StateNV

VIII. Authorized Official

Name: AJAY K NELLUTLA
Title or Position: PRESIDENT
Credential: MD
Phone: 702-649-8009