Provider Demographics
NPI:1619165289
Name:REIICHI IIZUKA, M.D. CHTD.
Entity Type:Organization
Organization Name:REIICHI IIZUKA, M.D. CHTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:REIICHI
Authorized Official - Middle Name:
Authorized Official - Last Name:IIZUKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-878-0070
Mailing Address - Street 1:3010 W CHARLESTON BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1966
Mailing Address - Country:US
Mailing Address - Phone:702-878-0070
Mailing Address - Fax:702-818-1930
Practice Address - Street 1:3010 W CHARLESTON BLVD
Practice Address - Street 2:STE 150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1966
Practice Address - Country:US
Practice Address - Phone:702-878-0070
Practice Address - Fax:702-818-1930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2426207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV39046Medicare PIN
NVC96174Medicare UPIN