Provider Demographics
NPI:1366444937
Name:MUJICA TRENCHE, SAMUEL ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ANTONIO
Last Name:MUJICA TRENCHE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 ROSANNA ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3137
Mailing Address - Country:US
Mailing Address - Phone:702-205-1948
Mailing Address - Fax:702-876-9181
Practice Address - Street 1:3265 ROSANNA ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3137
Practice Address - Country:US
Practice Address - Phone:702-205-1948
Practice Address - Fax:702-876-9181
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5456208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002938Medicaid
NV39202Medicare ID - Type UnspecifiedNORIDIAN
C96777Medicare UPIN