Provider Demographics
NPI:1033201082
Name:VICUNA, JOSELO ATIENZA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSELO
Middle Name:ATIENZA
Last Name:VICUNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 98978
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8978
Mailing Address - Country:US
Mailing Address - Phone:702-507-2486
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:2365 REYNOLDS AVE
Practice Address - Street 2:211
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7276
Practice Address - Country:US
Practice Address - Phone:702-399-1287
Practice Address - Fax:702-649-8064
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV3370208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1033201082Medicaid
NV105342Medicare PIN
C96664Medicare UPIN