Provider Demographics
NPI:1750598165
Name:DAVID VANSOMPHONE MD LTD
Entity type:Organization
Organization Name:DAVID VANSOMPHONE MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCTS. MGR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:LABRECQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-453-3799
Mailing Address - Street 1:PO BOX 35984
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5984
Mailing Address - Country:US
Mailing Address - Phone:702-597-1597
Mailing Address - Fax:
Practice Address - Street 1:5375 S FORT APACHE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-7623
Practice Address - Country:US
Practice Address - Phone:702-597-1597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV40594Medicare PIN
NVH25909Medicare UPIN