Provider Demographics
NPI:1619671658
Name:LAS VEGAS PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:LAS VEGAS PEDIATRICS, PLLC
Other - Org Name:LAS VEGAS PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIMI
Authorized Official - Middle Name:
Authorized Official - Last Name:KURIAKOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-250-8911
Mailing Address - Street 1:6070 S RAINBOW BLVD
Mailing Address - Street 2:UNIT 10
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-2503
Mailing Address - Country:US
Mailing Address - Phone:504-250-8911
Mailing Address - Fax:702-331-6018
Practice Address - Street 1:6070 S RAINBOW BLVD STE 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-2503
Practice Address - Country:US
Practice Address - Phone:702-420-7222
Practice Address - Fax:702-331-6018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-27
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250025509Medicaid