Provider Demographics
NPI:1447223839
Name:MUTHIALU, SMITHA (MD)
Entity Type:Individual
Prefix:
First Name:SMITHA
Middle Name:
Last Name:MUTHIALU
Suffix:
Gender:F
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:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-737-1880
Mailing Address - Fax:702-650-0763
Practice Address - Street 1:4475 S EASTERN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119
Practice Address - Country:US
Practice Address - Phone:702-737-1880
Practice Address - Fax:702-650-0763
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9869207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1447223839Medicaid
NV2018444Medicaid
NV3102444Medicaid
H43054Medicare UPIN
NVV35104Medicare PIN
NVFS618ZMedicare PIN