Healthcare Provider Details

I. General information

NPI: 1235344516
Provider Name (Legal Business Name): MEDICAL DIAGNOSTIC SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 09/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E WARM SPRINGS RD 301
LAS VEGAS NV
89119-4305
US

IV. Provider business mailing address

2300 CORPORATE CIR 190
HENDERSON NV
89074-7724
US

V. Phone/Fax

Practice location:
  • Phone: 702-318-2484
  • Fax: 702-932-8587
Mailing address:
  • Phone: 702-318-2484
  • Fax: 702-932-8587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State

VIII. Authorized Official

Name: MALISSA THATCHER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 702-932-8547