MEDICARE: GUADALUPE MEDICAL CENTER/OKAMOTO MD PC

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	208D00000X	General Practice Physician

Other Identifiers

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

General Provider Information

NPI Number	:	1598703506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUADALUPE MEDICAL CENTER/OKAMOTO MD PC

Provider Business Mailing Address
First Line	:	1219 E CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1708
Country	:	US
Telephone Number	:	702-633-5410
Fax Number	:	702-320-1639

Provider Business Practice Location Address
First Line	:	1219 E CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1708
Country	:	US
Telephone Number	:	702-633-5410
Fax Number	:	702-320-1639

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SANDRA ALDANA
Credential	:
Telephone Number	:	702-633-5410

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	05/10/2017

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