Provider Demographics
NPI:1750422481
Name:JAGANNATH S. SURPURE, M.D.P.C.
Entity type:Organization
Organization Name:JAGANNATH S. SURPURE, M.D.P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAGANNATH
Authorized Official - Middle Name:S
Authorized Official - Last Name:SURPURE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-898-6400
Mailing Address - Street 1:1600 W SUNSET RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2654
Mailing Address - Country:US
Mailing Address - Phone:702-898-6400
Mailing Address - Fax:702-898-7032
Practice Address - Street 1:1600 W SUNSET RD
Practice Address - Street 2:SUITE A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2654
Practice Address - Country:US
Practice Address - Phone:702-898-6400
Practice Address - Fax:702-898-7032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6591208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3102430Medicaid
NV2019436Medicaid
NV3102430Medicaid