Provider Demographics
NPI: | 1669472643 |
---|---|
Name: | TARQUINO, MARIO FERNANDO (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARIO |
Middle Name: | FERNANDO |
Last Name: | TARQUINO |
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: | 3111 S MARYLAND PKWY |
Mailing Address - Street 2: | SUITE 200 |
Mailing Address - City: | LAS VEGAS |
Mailing Address - State: | NV |
Mailing Address - Zip Code: | 89109-2303 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 702-968-6259 |
Mailing Address - Fax: | 702-987-3219 |
Practice Address - Street 1: | 3111 S MARYLAND PKWY |
Practice Address - Street 2: | SUITE 200 |
Practice Address - City: | LAS VEGAS |
Practice Address - State: | NV |
Practice Address - Zip Code: | 89109-2303 |
Practice Address - Country: | US |
Practice Address - Phone: | 702-968-6259 |
Practice Address - Fax: | 702-987-3219 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-07-29 |
Last Update Date: | 2008-03-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NV | 11543 | 207L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NV | 100500024 | Medicaid | |
NV | 100507087 | Medicaid | |
NV | CN3300 | Other | RAILROAD MEDICARE |
NV | CN3300 | Other | RAILROAD MEDICARE |
NV | V30408 | Medicare PIN | |
G38643 | Medicare UPIN |