Provider Demographics
NPI:1720060890
Name:MESQUITE MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:MESQUITE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.F.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:LLOYD
Authorized Official - Middle Name:
Authorized Official - Last Name:GATHERUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-346-0800
Mailing Address - Street 1:1301 BERTHA HOWE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-7502
Mailing Address - Country:US
Mailing Address - Phone:702-346-0800
Mailing Address - Fax:702-346-0801
Practice Address - Street 1:1301 BERTHA HOWE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-7502
Practice Address - Country:US
Practice Address - Phone:702-346-0800
Practice Address - Fax:702-346-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB355111N00000X
NVAPN00314207Q00000X
NV8194207Q00000X
NV97207Q00000X
NV0841207R00000X
NV10328207R00000X
NV10669208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPIN#38138OtherLEO BLACK, DC
AZ811621Medicaid
NVPIN#37972OtherENRIQUE ALFARO, MD
NVPIN#32238OtherLONNIE EMPEY, DO
AZ811580Medicaid
AZ811598Medicaid
NVPIN#36266OtherJEFFREY WRIGHT, PAC
NVH99428Medicare UPIN
NVG98619Medicare UPIN
AZ811621Medicaid
NVPIN#38138OtherLEO BLACK, DC
NVU97228Medicare UPIN
AZ811598Medicaid