Healthcare Provider Details

I. General information

NPI: 1306852975
Provider Name (Legal Business Name): SHANTALA BINDU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANTALA VIJAY

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 BURNHAM AVE
LAS VEGAS NV
89119
US

IV. Provider business mailing address

4230 BURNHAM AVENUE
LAS VEGAS NV
89119
US

V. Phone/Fax

Practice location:
  • Phone: 702-733-7866
  • Fax: 702-792-1319
Mailing address:
  • Phone: 702-733-7866
  • Fax: 702-733-8862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number11103
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: