Provider Demographics
NPI:1700838042
Name:MAHENDRA DEFONSEKA, MD, CHTD
Entity Type:Organization
Organization Name:MAHENDRA DEFONSEKA, MD, CHTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFONSEKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-565-3037
Mailing Address - Street 1:3022 S DURANGO DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-4439
Mailing Address - Country:US
Mailing Address - Phone:702-967-2352
Mailing Address - Fax:702-967-2354
Practice Address - Street 1:98 E LAKE MEAD PKWY
Practice Address - Street 2:SUITE 302
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-5540
Practice Address - Country:US
Practice Address - Phone:702-565-3037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV3983207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002520Medicaid
NV3383OtherBCBS
NV3383OtherBCBS
NV002002520Medicaid