1871562652 NPI number — DR. EUGENE G PORRECA M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871562652 NPI number — DR. EUGENE G PORRECA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORRECA
Provider First Name:
EUGENE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1871562652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9030 W SAHARA AVE
Provider Second Line Business Mailing Address:
#550
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89117-5744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-869-4554
Provider Business Mailing Address Fax Number:
702-228-5653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7106 SMOKE RANCH RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-869-4554
Provider Business Practice Location Address Fax Number:
702-796-9225
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  5987 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0129X , with the licence number: 5987 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 770589284 . This is a "TAX ID" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 002019002 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 770003058 . This is a "RR" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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