=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104816214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEB K. MUKHOPADHYAY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2005
-----------------------------------------------------
Last Update Date | 06/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 653 N TOWN CENTER DR SUITE #604
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89144-0514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-233-0666
-----------------------------------------------------
Fax | 702-233-8176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 33907
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89133-3907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-233-0666
-----------------------------------------------------
Fax | 702-233-8176
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 9249
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------