Provider Demographics
NPI:1568512101
Name:DESHAZO, GARY MAX (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:MAX
Last Name:DESHAZO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:MAX
Other - Last Name:DESHAZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2901 N TENAYA WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-1404
Mailing Address - Country:US
Mailing Address - Phone:702-870-8852
Mailing Address - Fax:702-870-8914
Practice Address - Street 1:2901 N TENAYA WAY STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1404
Practice Address - Country:US
Practice Address - Phone:702-870-8852
Practice Address - Fax:702-870-8914
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3802083P0901X, 261QC1500X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC4619OtherBLUE CROSS PIN
NV002002672Medicaid
NV002002672Medicaid
NVV38875Medicare PIN