Provider Demographics
NPI:1144266537
Name:PORFERIA D MONTESCLAROS, MD, LLC
Entity type:Organization
Organization Name:PORFERIA D MONTESCLAROS, MD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PORFERIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MONTESCLAROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-243-7607
Mailing Address - Street 1:PO BOX 230146
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89105-0146
Mailing Address - Country:US
Mailing Address - Phone:702-382-7878
Mailing Address - Fax:702-248-9524
Practice Address - Street 1:6450 SPRING MOUNTAIN RD
Practice Address - Street 2:SUITE 8
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-8853
Practice Address - Country:US
Practice Address - Phone:702-382-7878
Practice Address - Fax:702-248-9524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV102309Medicare ID - Type Unspecified
NV102310Medicare ID - Type Unspecified