Provider Demographics
NPI:1891004198
Name:TANITA, DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:TANITA
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 1:650 S GREEN VALLEY PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-0425
Mailing Address - Country:US
Mailing Address - Phone:702-847-6252
Mailing Address - Fax:702-847-6254
Practice Address - Street 1:650 S GREEN VALLEY PKWY STE 120
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-0425
Practice Address - Country:US
Practice Address - Phone:702-847-6252
Practice Address - Fax:702-847-6254
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV13860207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250009085Medicaid
NV1891004198Medicaid