Provider Demographics
NPI:1013964824
Name:SRINIVAS VUTHOORI, MD, PC
Entity Type:Organization
Organization Name:SRINIVAS VUTHOORI, MD, PC
Other - Org Name:ODYSSEY MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:
Authorized Official - Last Name:VUTHOORI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-407-8241
Mailing Address - Street 1:PO BOX 36670
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-6670
Mailing Address - Country:US
Mailing Address - Phone:702-407-8241
Mailing Address - Fax:702-492-1728
Practice Address - Street 1:2610 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE #103
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2869
Practice Address - Country:US
Practice Address - Phone:702-407-8241
Practice Address - Fax:702-492-1728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10013207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV36404Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER