Provider Demographics
NPI:1568478840
Name:KITTUSAMY, PREM K (MD)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:K
Last Name:KITTUSAMY
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 1:401 N BUFFALO DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-0397
Mailing Address - Country:US
Mailing Address - Phone:702-489-9000
Mailing Address - Fax:702-489-9001
Practice Address - Street 1:401 N BUFFALO DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0310
Practice Address - Country:US
Practice Address - Phone:702-489-9000
Practice Address - Fax:702-489-9001
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069834L207RC0000X
NV10827207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBM4472OtherMEDICARE ID TYPE
NV100503391Medicaid
NVBM4472OtherMEDICARE ID TYPE