Provider Demographics
NPI:1497799258
Name:DAMASCO TY, EDESON GO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDESON
Middle Name:GO
Last Name:DAMASCO TY
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 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:6355 S BUFFALO DR FL 3
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2133
Practice Address - Country:US
Practice Address - Phone:702-952-9171
Practice Address - Fax:702-952-9170
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1497799258Medicaid
NVGB004Y (CQ328B)Medicare PIN
NVGB004Z (CQ328A)Medicare PIN
NV1497799258Medicaid