Provider Demographics
NPI:1679816987
Name:DAVE, MIT P (MD)
Entity Type:Individual
Prefix:DR
First Name:MIT
Middle Name:P
Last Name:DAVE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:APT. 4
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-8600
Mailing Address - Fax:702-242-7944
Practice Address - Street 1:2716 N TENAYA WAY FL 4
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:702-877-8600
Practice Address - Fax:702-242-7944
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NV16706207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV114695Medicare PIN