Healthcare Provider Details

I. General information

NPI: 1457305625
Provider Name (Legal Business Name): ALLEN BRADFORD THACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 N TOWN CENTER DRIVE SUITE 518
LAS VEGAS NV
89144
US

IV. Provider business mailing address

653 N TOWN CENTER DRIVE SUITE 518
LAS VEGAS NV
89144
US

V. Phone/Fax

Practice location:
  • Phone: 702-369-0200
  • Fax: 702-243-8383
Mailing address:
  • Phone: 702-369-0200
  • Fax: 702-243-8383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number10505
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number10505
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: