=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164184081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUBDER HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2021
-----------------------------------------------------
Last Update Date | 10/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 W CHARLESTON BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89102-2329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-383-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3022 S DURANGO DR STE 100
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-4440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-256-3637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGING MEMBER
-----------------------------------------------------
Name | MOHAMAD MUBDER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 313-358-2387
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------