Basic Information
| Provider Information | |||||||||
| NPI: | 1417046822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOCK | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 E SILVERADO RANCH BLVD STE 170 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891837518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022406482 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2800 N TENAYA WAY | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891281100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022558877 | ||||||||
| FaxNumber: | 7022558813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 7780 | NV | N | Other Service Providers | Specialist | 207RC0000X | 7780 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 002019815 | 05 | NV | MEDICAID |