Provider Demographics
NPI:1649225293
Name:POTRUCH, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:POTRUCH
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 1:2123 CIVIC CENTER DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-6327
Mailing Address - Country:US
Mailing Address - Phone:702-333-1110
Mailing Address - Fax:702-685-0744
Practice Address - Street 1:2123 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-6327
Practice Address - Country:US
Practice Address - Phone:702-333-1110
Practice Address - Fax:702-685-0744
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2018-03-06
Deactivation Date:2008-01-22
Deactivation Code:
Reactivation Date:2008-02-12
Provider Licenses
StateLicense IDTaxonomies
NV3310208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV50306OtherMEDICARE PTAN