Provider Demographics
NPI:1023212552
Name:DOMINIC RICCIARDI MD LTD
Entity Type:Organization
Organization Name:DOMINIC RICCIARDI MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:RICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-492-8281
Mailing Address - Street 1:6284 S RAINBOW BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-3244
Mailing Address - Country:US
Mailing Address - Phone:702-492-8281
Mailing Address - Fax:702-492-8279
Practice Address - Street 1:8285 W ARBY AVE STE 145
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2236
Practice Address - Country:US
Practice Address - Phone:702-492-8281
Practice Address - Fax:702-491-8279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20061204813207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVI18196Medicare UPIN
NVV104118Medicare PIN