Provider Demographics
NPI:1770042079
Name:UNDERWOOD, MAHDIKA KEYONNA (DO)
Entity Type:Individual
Prefix:
First Name:MAHDIKA
Middle Name:KEYONNA
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MAHDIKA
Other - Middle Name:KEYONNA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 RANCHO LN STE 135
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3826
Mailing Address - Country:US
Mailing Address - Phone:702-780-7587
Mailing Address - Fax:
Practice Address - Street 1:901 RANCHO LN STE 135
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3826
Practice Address - Country:US
Practice Address - Phone:702-383-7885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-16
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NVDO32452080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program