Provider Demographics
NPI:1821032244
Name:RANDA BASCHARON D.O., INC
Entity Type:Organization
Organization Name:RANDA BASCHARON D.O., INC
Other - Org Name:ORTHOPEDIC & SPORTS MEDICINE INSTITUTE OF LAS VEGAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES SEC ETC
Authorized Official - Prefix:
Authorized Official - First Name:RANDA
Authorized Official - Middle Name:AMIN
Authorized Official - Last Name:BASCHARON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:702-596-0036
Mailing Address - Street 1:4132 S RAINBOW BLVD
Mailing Address - Street 2:#393
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-3106
Mailing Address - Country:US
Mailing Address - Phone:702-596-0036
Mailing Address - Fax:702-947-7792
Practice Address - Street 1:500 E WINDMILL LN
Practice Address - Street 2:# 125
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-1843
Practice Address - Country:US
Practice Address - Phone:702-947-7790
Practice Address - Fax:702-947-7792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1103207X00000X, 207XX0005X
CA20A8358207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXTE006922OtherCALIF MEDI-CAL
NV100503044Medicaid
CAXTE006922OtherCALIF MEDI-CAL
NV5771800005Medicare NSC
NV5771800004Medicare NSC
NV102676Medicare ID - Type UnspecifiedNV GROUP PROV ID #
NV5771800006Medicare NSC
CA020A8358Medicare ID - Type UnspecifiedCALIF MEDICARE ID
NV100503044Medicaid