Provider Demographics
NPI:1720198914
Name:RICCIARDI, DOMINIC L (MD)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:L
Last Name:RICCIARDI
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 1:5572 S FORT APACHE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-3605
Mailing Address - Country:US
Mailing Address - Phone:702-503-5592
Mailing Address - Fax:702-974-1268
Practice Address - Street 1:5572 S FORT APACHE RD STE 110
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-3605
Practice Address - Country:US
Practice Address - Phone:702-492-8281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100511080Medicaid
NV100511080Medicaid