Active NPI
Theodore Potruch, MD
- Surgery Physician
- North Las Vegas, NV
National Provider Identifier
1649225293
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgery Physician
- License
- 3310
- Practice address
- 2123 Civic Center Dr
North Las Vegas, NV 89030-6327 - Phone
- (702) 333-1110
- Fax
- (702) 685-0744
- NPI assigned
- May 23, 2006
- Reactivated
- Feb 12, 2008
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Surgery Physician | 208600000X | 3310 | NV | Primary |
Addresses
Primary practice location
2123 Civic Center Dr
North Las Vegas, NV 89030-6327
Mailing address
2123 Civic Center Dr
North Las Vegas, NV 89030-6327
Phone (702) 333-1110
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| V50306 | Other | NV | MEDICARE PTAN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3310 | NV | MD | Physical Therapist |
| 3310 | CA | MD | Pediatric Occupational Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1148342400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1520294400000",
"number": "1649225293",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2123 CIVIC CENTER DR",
"city": "NORTH LAS VEGAS",
"state": "NV",
"postal_code": "890306327",
"telephone_number": "702-333-1110",
"fax_number": "702-685-0744"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2123 CIVIC CENTER DR",
"city": "NORTH LAS VEGAS",
"state": "NV",
"postal_code": "890306327",
"telephone_number": "702-333-1110",
"fax_number": "702-685-0744"
}
],
"practiceLocations": [],
"basic": {
"last_name": "POTRUCH",
"first_name": "THEODORE",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-23",
"last_updated": "2018-03-06",
"deactivation_date": "2008-01-22",
"reactivation_date": "2008-02-12",
"status": "A"
},
"taxonomies": [
{
"code": "208600000X",
"taxonomy_group": "",
"desc": "Surgery",
"state": "NV",
"license": "3310",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE PTAN",
"identifier": "V50306",
"state": "NV"
}
],
"endpoints": [],
"other_names": []
}Other providers in North Las Vegas, NV
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 6, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.