Provider Demographics
NPI:1437584067
Name:BANTHIA, DEEPA
Entity Type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:
Last Name:BANTHIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 QUEST PARK ST
Mailing Address - Street 2:APT. 721
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-1481
Mailing Address - Country:US
Mailing Address - Phone:757-748-7733
Mailing Address - Fax:
Practice Address - Street 1:3030 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-5756
Practice Address - Country:US
Practice Address - Phone:757-748-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV18477183500000X
VA0202210797183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist