Healthcare Provider Details

I. General information

NPI: 1083810212
Provider Name (Legal Business Name): MICHAEL VATHANASAYNEE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 W LAKE MEAD BLVD
N LAS VEGAS NV
89032-4895
US

IV. Provider business mailing address

11714 LONGWORTH RD
LAS VEGAS NV
89135-1322
US

V. Phone/Fax

Practice location:
  • Phone: 702-737-2020
  • Fax:
Mailing address:
  • Phone: 714-926-4384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009940
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number609
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: