Basic Information
| Provider Information | |||||||||
| NPI: | 1720173602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIGORIEV | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7150 W SUNSET RD | ||||||||
| Address2: | SUITE 201A | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891131981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023854342 | ||||||||
| FaxNumber: | 7023854346 | ||||||||
| Practice Location | |||||||||
| Address1: | 7500 SMOKE RANCH RD. | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022330727 | ||||||||
| FaxNumber: | 7022334799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 02/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 7212 | NV | Y | Allopathic & Osteopathic Physicians | Urology | 2088F0040X | 7212 | NV | N | Allopathic & Osteopathic Physicians | Urology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1720143602 | 05 | NV | MEDICAID |