Provider Demographics
NPI:1598743916
Name:FOUSE, MERVYN BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:MERVYN
Middle Name:BRUCE
Last Name:FOUSE
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 50509
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89016-0509
Mailing Address - Country:US
Mailing Address - Phone:702-731-1616
Mailing Address - Fax:702-731-0741
Practice Address - Street 1:2800 E DESERT INN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3608
Practice Address - Country:US
Practice Address - Phone:702-731-1616
Practice Address - Fax:702-731-0741
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5401207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2002961Medicaid
NV8839OtherBXBS
200006951OtherR.R. MEDICARE
4294880OtherAETNA
NV8839OtherBXBS
4294880OtherAETNA