Provider Demographics
NPI:1104809433
Name:FRAGA, GUILLERMO (MD)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:FRAGA
Suffix:
Gender:M
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-724-8777
Mailing Address - Fax:702-724-8749
Practice Address - Street 1:2610 W. HORIZON PKWY.
Practice Address - Street 2:SUITE 105
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052
Practice Address - Country:US
Practice Address - Phone:702-724-8777
Practice Address - Fax:702-724-8749
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7867207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019808Medicaid
NV002019808Medicaid
NVV109512Medicare PIN