Healthcare Provider Details

I. General information

NPI: 1114961539
Provider Name (Legal Business Name): RANDA BASCHARON,D.O. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7281 W SAHARA AVE SUITE 110
LAS VEGAS NV
89117-2816
US

IV. Provider business mailing address

4132 S RAINBOW BLVD #393
LAS VEGAS NV
89103-3106
US

V. Phone/Fax

Practice location:
  • Phone: 702-947-7790
  • Fax: 702-947-7792
Mailing address:
  • Phone: 702-596-0036
  • Fax: 702-947-7792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2OA8358
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number1103
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number2OA8358
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number1103
License Number StateNV

VIII. Authorized Official

Name: RANDA AMIN BASCHARON
Title or Position: PRES, SEC,
Credential: DO
Phone: 702-596-0036