Provider Demographics
NPI:1457577827
Name:VICUNA, MYLENE B (MD)
Entity Type:Individual
Prefix:DR
First Name:MYLENE
Middle Name:B
Last Name:VICUNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MYLENE
Other - Middle Name:ABASOLO
Other - Last Name:BERSAMINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6900 N PECOS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086-4400
Mailing Address - Country:US
Mailing Address - Phone:702-791-9000
Mailing Address - Fax:702-791-9000
Practice Address - Street 1:6900 N PECOS RD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-4400
Practice Address - Country:US
Practice Address - Phone:702-791-9000
Practice Address - Fax:702-791-9000
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2023-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125048180208D00000X
NV12460207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBF282YMedicare PIN
NVBF282ZMedicare PIN
NV104703Medicare PIN