MEDICARE: MAHENDRA DEFONSEKA M.D.

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	207RG0100X	Gastroenterology Physician	3983	NV

General Provider Information

NPI Number	:	1699775684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAHENDRA DEFONSEKA M.D.

Provider Business Mailing Address
First Line	:	8010 W SAHARA AVE
Second Line	:	SUITE 235
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-7905
Country	:	US
Telephone Number	:	702-256-3637
Fax Number	:	702-256-3307

Provider Business Practice Location Address
First Line	:	2610 W HORIZON RIDGE PKWY
Second Line	:	SUITE 105
City	:	HENDERSON
State	:	NV
Zip	:	89052-2869
Country	:	US
Telephone Number	:	702-565-3037
Fax Number	:

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

Provider Enumeration Date	:	07/30/2005
Last Update Date	:	07/08/2007

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