Provider Demographics
NPI:1487663795
Name:AJEET MAHENDERNATH MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:AJEET MAHENDERNATH MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCTS. MGRE
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:LABRECQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-453-3799
Mailing Address - Street 1:2505 ANTHEM VILLAGE DR STE E-603
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5505
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:
Practice Address - Street 1:2505 ANTHEM VILLAGE DR STE E-603
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5505
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:702-453-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV102199Medicare ID - Type Unspecified
H52093Medicare UPIN