Provider Demographics
NPI:1326488131
Name:RAMIREZ, ILDEFONSO (MED)
Entity Type:Individual
Prefix:MR
First Name:ILDEFONSO
Middle Name:
Last Name:RAMIREZ
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:568 ENGEL WAY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89011-4432
Mailing Address - Country:US
Mailing Address - Phone:484-201-9089
Mailing Address - Fax:
Practice Address - Street 1:720 W CHEYENNE AVE STE 20
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7817
Practice Address - Country:US
Practice Address - Phone:702-487-5665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12345678103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA25390920Medicaid