Provider Demographics
NPI:1619925476
Name:BACCHUS, AMIR (MD)
Entity Type:Individual
Prefix:
First Name:AMIR
Middle Name:
Last Name:BACCHUS
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 1:700 E WARM SPRINGS RD
Mailing Address - Street 2:#302
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-4305
Mailing Address - Country:US
Mailing Address - Phone:702-216-3350
Mailing Address - Fax:702-216-3356
Practice Address - Street 1:700 E WARM SPRINGS RD
Practice Address - Street 2:302
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-4305
Practice Address - Country:US
Practice Address - Phone:702-932-8582
Practice Address - Fax:702-932-8587
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7888207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00201979Medicaid
NV65-1280664OtherTAX ID NUMBER
NV74-3177329OtherSECOND TAX ID NUMBER
NV74-3177329OtherSECOND TAX ID NUMBER
NVV105542Medicare PIN