Healthcare Provider Details

I. General information

NPI: 1811966062
Provider Name (Legal Business Name): STEFAN NATHAN CHOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 04/10/2020
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 LA CANADA ST STE 217
LAS VEGAS NV
89169-2579
US

IV. Provider business mailing address

3131 LA CANADA ST STE 217
LAS VEGAS NV
89169-2579
US

V. Phone/Fax

Practice location:
  • Phone: 702-369-7152
  • Fax: 702-369-7153
Mailing address:
  • Phone: 702-369-7152
  • Fax: 702-369-7153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number11562
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number11562
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: