Healthcare Provider Details

I. General information

NPI: 1730119413
Provider Name (Legal Business Name): SRINIVAS N. HALTHORE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 S CEDAR CREST BLVD STE 2400
ALLENTOWN PA
18103-6235
US

IV. Provider business mailing address

2020 E DESERT INN RD
LAS VEGAS NV
89109-3211
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-3888
  • Fax:
Mailing address:
  • Phone: 702-796-5505
  • Fax: 702-732-9830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number7067
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number7067
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberMD485391
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: