Healthcare Provider Details

I. General information

NPI: 1770132466
Provider Name (Legal Business Name): JUSTAN DEGENEFFE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7676 SILVER BARON RD
LAS VEGAS NV
89179-2070
US

IV. Provider business mailing address

7676 SILVER BARON RD
LAS VEGAS NV
89179-2070
US

V. Phone/Fax

Practice location:
  • Phone: 702-406-2325
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number181456
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: