Basic Information
| Provider Information | |||||||||
| NPI: | 1659478527 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INFECTIOUS DISEASE DOCTORS OF NEVADA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3022 S DURANGO DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891174439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022563637 | ||||||||
| FaxNumber: | 7022563307 | ||||||||
| Practice Location | |||||||||
| Address1: | 4445 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517883000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | MALLELA | ||||||||
| AuthorizedOfficialFirstName: | SUDHAKAR | ||||||||
| AuthorizedOfficialMiddleName: | V. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7028783235 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 9640 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.