Provider Demographics
NPI:1740287192
Name:CRUVANT, ETHAN MILTON (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:MILTON
Last Name:CRUVANT
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 1:8205 W. WARM SPRINGS RD.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-3612
Mailing Address - Country:US
Mailing Address - Phone:702-735-8734
Mailing Address - Fax:702-735-2726
Practice Address - Street 1:8205 W. WARM SPRINGS RD.
Practice Address - Street 2:SUITE 110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113
Practice Address - Country:US
Practice Address - Phone:702-735-8734
Practice Address - Fax:702-735-2726
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5854208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019008Medicaid
110227382OtherRAILROAD MEDICARE
880344806A002OtherTRIWEST
110227382OtherRAILROAD MEDICARE
NV002019008Medicaid