Provider Demographics
NPI:1780790741
Name:BRIAN CITRO MD PC
Entity type:Organization
Organization Name:BRIAN CITRO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-798-3008
Mailing Address - Street 1:PO BOX 50204
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89016-0204
Mailing Address - Country:US
Mailing Address - Phone:702-648-9400
Mailing Address - Fax:702-636-0249
Practice Address - Street 1:3150 N TENAYA WAY
Practice Address - Street 2:SUITE 550
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0443
Practice Address - Country:US
Practice Address - Phone:702-648-9400
Practice Address - Fax:702-636-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11968208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV103447Medicare PIN