Provider Demographics
NPI:1962403121
Name:VISTA MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:VISTA MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOFI
Authorized Official - Middle Name:E
Authorized Official - Last Name:SARFO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-798-1233
Mailing Address - Street 1:PO BOX 365404
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89036-9404
Mailing Address - Country:US
Mailing Address - Phone:702-798-1233
Mailing Address - Fax:702-531-1233
Practice Address - Street 1:2909 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1925
Practice Address - Country:US
Practice Address - Phone:702-798-1233
Practice Address - Fax:702-531-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H74629Medicare UPIN
NVV101184Medicare PIN