Provider Demographics
NPI:1699775684
Name:DEFONSEKA, MAHENDRA (MD)
Entity type:Individual
Prefix:
First Name:MAHENDRA
Middle Name:
Last Name:DEFONSEKA
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 1:8010 W SAHARA AVE
Mailing Address - Street 2:SUITE 235
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7905
Mailing Address - Country:US
Mailing Address - Phone:702-256-3637
Mailing Address - Fax:702-256-3307
Practice Address - Street 1:2610 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-2869
Practice Address - Country:US
Practice Address - Phone:702-565-3037
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3983207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVC95954Medicare UPIN
NV30072Medicare ID - Type Unspecified