Healthcare Provider Details

I. General information

NPI: 1265814628
Provider Name (Legal Business Name): MUSTAPHA IBRAHIM SERHAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 09/19/2021
Certification Date: 09/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 S FORT APACHE RD STE 100
LAS VEGAS NV
89148-5613
US

IV. Provider business mailing address

6040 S FORT APACHE RD STE 100
LAS VEGAS NV
89148-5613
US

V. Phone/Fax

Practice location:
  • Phone: 702-476-4900
  • Fax:
Mailing address:
  • Phone: 702-476-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number20823
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number20823
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: