Provider Demographics
NPI:1780698456
Name:PHILLIPS, MARYANNE DEFOREST (MD)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:DEFOREST
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10620 SOUTHERN HIGHLANDS PKWY
Mailing Address - Street 2:110-250
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-4369
Mailing Address - Country:US
Mailing Address - Phone:702-822-1881
Mailing Address - Fax:702-822-1880
Practice Address - Street 1:5052 JONES BLVD
Practice Address - Street 2:135
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118
Practice Address - Country:US
Practice Address - Phone:702-822-1881
Practice Address - Fax:702-822-1880
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7635174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A637530OtherBLUE SHIELD
CA00A637530Medicaid
CA00A637530Medicaid
CAWA63753AMedicare ID - Type Unspecified