Provider Demographics
NPI:1649729161
Name:HOMAYON IRANINEZHAD DO PC
Entity type:Organization
Organization Name:HOMAYON IRANINEZHAD DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:XENETEIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AQUINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-818-9397
Mailing Address - Street 1:PO BOX 371086
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89137-1086
Mailing Address - Country:US
Mailing Address - Phone:702-623-6454
Mailing Address - Fax:702-666-0374
Practice Address - Street 1:201 N BUFFALO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0373
Practice Address - Country:US
Practice Address - Phone:702-623-3454
Practice Address - Fax:702-666-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1453207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty