Provider Demographics
NPI:1730119413
Name:HALTHORE, SRINIVAS N (MD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:N
Last Name:HALTHORE
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 1:2020 E DESERT INN RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-3211
Mailing Address - Country:US
Mailing Address - Phone:702-796-5505
Mailing Address - Fax:702-732-9830
Practice Address - Street 1:2020 E DESERT INN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-3211
Practice Address - Country:US
Practice Address - Phone:702-796-5505
Practice Address - Fax:702-732-9830
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV70672084N0402X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019640Medicaid
NVWQBDW-01Medicare ID - Type Unspecified