Provider Demographics
NPI:1528402351
Name:TUAZON, MITZILENE ANNE ALFONSO (MD)
Entity Type:Individual
Prefix:
First Name:MITZILENE
Middle Name:ANNE ALFONSO
Last Name:TUAZON
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:702-650-2458
Practice Address - Street 1:4475 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7826
Practice Address - Country:US
Practice Address - Phone:702-737-1880
Practice Address - Fax:702-650-2458
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL157598207QA0505X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVSMA MEDICAREOtherV114219
KYK149201Medicare PIN
NVSMA MEDICAREOtherV114219
KYK149200Medicare PIN