Provider Demographics
NPI:1548424583
Name:HIRATA, SUSAN REIKO (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:REIKO
Last Name:HIRATA
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 1:3006 S MARYLAND PKWY
Mailing Address - Street 2:STE. #530
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2218
Mailing Address - Country:US
Mailing Address - Phone:702-796-1820
Mailing Address - Fax:702-796-3938
Practice Address - Street 1:3006 S MARYLAND PKWY
Practice Address - Street 2:STE #530
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2218
Practice Address - Country:US
Practice Address - Phone:702-796-1820
Practice Address - Fax:702-796-3938
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13593208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100520286Medicaid