Provider Demographics
NPI:1275546590
Name:GASPAR DE ALBA, MARIO J (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:GASPAR DE ALBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3016 W CHARLESTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:630 S RANCHO DR STE A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4849
Practice Address - Country:US
Practice Address - Phone:702-998-9505
Practice Address - Fax:702-527-7939
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM32322080P0006X
NV145542080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1275546590Medicaid
TX178999201Medicaid
NVGW226ZOtherMEDICARE
TX8H0437OtherBC/BS OF TEXAS