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General NPI Number Information
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NPI Number | 1700838042
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Entity Type | Organization
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Legal Business Name | MAHENDRA DEFONSEKA, MD, CHTD
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Dates
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Enumeration Date | 05/16/2006
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Last Update Date | 03/05/2014
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Provider Practice Location Address
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Address Line | 98 E LAKE MEAD PKWY SUITE 302
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City | HENDERSON
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State | NV
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Zip | 89015-5540
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Country | US
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Telephone | 702-565-3037
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Fax |
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Provider Business Mailing Address
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Address Line | 3022 S DURANGO DR SUITE 100
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City | LAS VEGAS
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State | NV
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Zip | 89117-4439
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Country | US
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Telephone | 702-967-2352
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Fax | 702-967-2354
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Authorized Official
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Title or Position | OWNER
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Name | MAHENDRA DEFONSEKA
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Credential | M.D.
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Telephone | 702-565-3037
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | NV3983
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License Number State | NV
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