Provider Demographics
NPI:1477714525
Name:BOMSZTYK, ELAN DAHL (MD)
Entity Type:Individual
Prefix:DR
First Name:ELAN
Middle Name:DAHL
Last Name:BOMSZTYK
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 1:2020 PALOMINO LANE
Mailing Address - Street 2:STE # 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4894
Mailing Address - Country:US
Mailing Address - Phone:702-759-8600
Mailing Address - Fax:702-384-1815
Practice Address - Street 1:2020 PALOMINO LANE
Practice Address - Street 2:STE # 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4894
Practice Address - Country:US
Practice Address - Phone:702-759-8600
Practice Address - Fax:702-384-1815
Is Sole Proprietor?:No
Enumeration Date:2008-06-21
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV154302085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1477714525Medicaid
NVP01374967OtherRR MEDICARE DR
CA1477714525Medicaid
NVP01374895OtherRR MEDICARE DRS
NVV108010Medicare PIN
NVP01374967OtherRR MEDICARE DR
NVV108046Medicare PIN