Provider Demographics
NPI:1720141120
Name:GARDUNO, JAVIER ISMAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JAVIER
Middle Name:ISMAEL
Last Name:GARDUNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ISMAEL
Other - Middle Name:XAVIER
Other - Last Name:GARDUNO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-877-5199
Mailing Address - Fax:702-259-0128
Practice Address - Street 1:4750 W OAKEY BLVD STE 3A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1535
Practice Address - Country:US
Practice Address - Phone:702-877-5319
Practice Address - Fax:702-259-0128
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15440207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1720141120Medicaid
NVV108216Medicare PIN