MEDICARE: MAHENDRA DEFONSEKA, MD, CHTD

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	NV3983	NV

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
2	NV3383	OTHER		BCBS

General Provider Information

NPI Number	:	1700838042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAHENDRA DEFONSEKA, MD, CHTD

Provider Business Mailing Address
First Line	:	3022 S DURANGO DR
Second Line	:	SUITE 100
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-4439
Country	:	US
Telephone Number	:	702-967-2352
Fax Number	:	702-967-2354

Provider Business Practice Location Address
First Line	:	98 E LAKE MEAD PKWY
Second Line	:	SUITE 302
City	:	HENDERSON
State	:	NV
Zip	:	89015-5540
Country	:	US
Telephone Number	:	702-565-3037
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MAHENDRA DEFONSEKA
Credential	:	M.D.
Telephone Number	:	702-565-3037

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	03/05/2014

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