Provider Demographics
NPI:1528043460
Name:DAWN, BUDDHADEB (MD)
Entity Type:Individual
Prefix:
First Name:BUDDHADEB
Middle Name:
Last Name:DAWN
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 1:3016 W CHARLESTON BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:702-218-0915
Mailing Address - Fax:
Practice Address - Street 1:1707 W CHARLESTON BLVD STE 230
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2353
Practice Address - Country:US
Practice Address - Phone:702-671-2201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33219207RC0000X
MO2010030195207RC0000X
KS04-34507207RC0000X
NV18127207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1528043460Medicaid
KS200679520AMedicaid
NV1528043460Medicaid
NVV55871OtherMEDICARE
MO1528043460Medicaid
KYH24910Medicare UPIN
KS200679520AMedicaid
KS110330026Medicare PIN
MO038E00017Medicare PIN
MO038E00017Medicare PIN