Provider Demographics
NPI:1972573178
Name:BHOGINENI-THAKORE, SUSMITA (MD)
Entity type:Individual
Prefix:
First Name:SUSMITA
Middle Name:
Last Name:BHOGINENI-THAKORE
Suffix:
Gender:F
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-560-2879
Mailing Address - Fax:702-560-2928
Practice Address - Street 1:650 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110
Practice Address - Country:US
Practice Address - Phone:702-459-7424
Practice Address - Fax:702-459-0320
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506075Medicaid
NV100506076Medicaid
NV100795Medicare ID - Type Unspecified
I30066Medicare UPIN