Provider Demographics
NPI:1578520896
Name:BRALLIAR, RICHARD J (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
Last Name:BRALLIAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7930 W SAHARA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-1990
Mailing Address - Country:US
Mailing Address - Phone:702-406-6758
Mailing Address - Fax:702-852-0348
Practice Address - Street 1:2445 FIRE MESA ST
Practice Address - Street 2:270
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9014
Practice Address - Country:US
Practice Address - Phone:702-876-9330
Practice Address - Fax:702-876-9061
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019185Medicaid
NV30290Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NV002019185Medicaid