Healthcare Provider Details

I. General information

NPI: 1093913378
Provider Name (Legal Business Name): SHAHAB MOKHTARE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9811 W CHARLESTON BLVD SUITE 2441
LAS VEGAS NV
89117-7528
US

IV. Provider business mailing address

9811 W CHARLESTON BLVD STE 2-441
LAS VEGAS NV
89117-7528
US

V. Phone/Fax

Practice location:
  • Phone: 702-953-1576
  • Fax:
Mailing address:
  • Phone: 702-420-7704
  • Fax: 702-420-7704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNV13663
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: