Provider Demographics
NPI:1730294455
Name:INGHAM, MAXINE BONNIE (MD)
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:BONNIE
Last Name:INGHAM
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 1:920 W OWENS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2516
Mailing Address - Country:US
Mailing Address - Phone:702-864-6622
Mailing Address - Fax:702-685-9014
Practice Address - Street 1:920 W OWENS AVE STE B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2516
Practice Address - Country:US
Practice Address - Phone:702-846-6622
Practice Address - Fax:702-685-9014
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8528207R00000X, 207RA0401X, 208M00000X, 261QP2300X, 207Q00000X
CAC42144207RA0401X, 208M00000X
IDM-10233207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016755Medicaid
NVV35181Medicare PIN
NV002016755Medicaid