Provider Demographics
NPI:1588646830
Name:JORGENSON, CRAIG M (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:M
Last Name:JORGENSON
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:PO BOX 530010
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89053-0010
Mailing Address - Country:US
Mailing Address - Phone:702-492-7208
Mailing Address - Fax:702-616-0657
Practice Address - Street 1:9975 S EASTERN AVE STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-7950
Practice Address - Country:US
Practice Address - Phone:702-361-2273
Practice Address - Fax:702-361-6885
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9529207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1588646830Medicaid
NV101737Medicare ID - Type UnspecifiedGROUP
NV101738Medicare ID - Type UnspecifiedINDIVIDUAL
NVH24279Medicare UPIN
NVH24279Medicare UPIN