Provider Demographics
NPI:1780139048
Name:JORGE BURGOS, MD
Entity type:Organization
Organization Name:JORGE BURGOS, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:E
Authorized Official - Last Name:FLATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-463-9820
Mailing Address - Street 1:1815 E LAKE MEAD BLVD STE 314
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-7193
Mailing Address - Country:US
Mailing Address - Phone:702-227-0022
Mailing Address - Fax:702-227-0084
Practice Address - Street 1:6440 SKY POINTE DR # 140-239
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-4047
Practice Address - Country:US
Practice Address - Phone:702-227-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10622207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVAQ146Medicare PIN