1063715761 NPI number — DEBRA M DOODKEVITCH

Table of content: ANGELA DENISE HURST WHNP (NPI 1588328199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063715761 NPI number — DEBRA M DOODKEVITCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEBRA M DOODKEVITCH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063715761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5530 KINGS ROW CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89148-4658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-228-8236
Provider Business Mailing Address Fax Number:
702-442-7190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5600 SPRING MOUNTAIN RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89146-8821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-228-8236
Provider Business Practice Location Address Fax Number:
702-442-7190
Provider Enumeration Date:
12/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DOODKEVITCH
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER, DIRECTOR
Authorized Official Telephone Number:
702-228-8236

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  5682-C , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100518693 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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