Provider Demographics
NPI:1740269703
Name:EARL, CAMERON I (MD)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:I
Last Name:EARL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 N TOWN CENTER DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-0514
Mailing Address - Country:US
Mailing Address - Phone:702-939-3436
Mailing Address - Fax:702-939-3437
Practice Address - Street 1:653 N TOWN CENTER DR
Practice Address - Street 2:SUITE 108
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0514
Practice Address - Country:US
Practice Address - Phone:702-939-3436
Practice Address - Fax:702-939-3437
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45965208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN764475200Medicaid
NVV10447OtherMEDICARE GROUP NUMBER
MN240000273Medicare ID - Type Unspecified
MNP00054237Medicare ID - Type UnspecifiedRAILROAD
NVV104458Medicare PIN
MN764475200Medicaid