MEDICARE: DR. PREM K KITTUSAMY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	MD069834L	PA
2	207RC0000X	Cardiovascular Disease Physician	10827	NV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BM4472	OTHER	NV	MEDICARE ID TYPE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568478840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PREM K KITTUSAMY MD

Provider Business Mailing Address
First Line	:	401 N BUFFALO DR STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-0397
Country	:	US
Telephone Number	:	702-489-9000
Fax Number	:	702-489-9001

Provider Business Practice Location Address
First Line	:	401 N BUFFALO DR
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-0310
Country	:	US
Telephone Number	:	702-489-9000
Fax Number	:	702-489-9001

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	02/07/2018

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Directions to “ DR. PREM K KITTUSAMY MD” Practice Location

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