Provider Demographics
NPI:1093913378
Name:MOKHTARE, SHAHAB (MD)
Entity Type:Individual
Prefix:
First Name:SHAHAB
Middle Name:
Last Name:MOKHTARE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S RAMPART BLVD
Mailing Address - Street 2:STE 420
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-5749
Mailing Address - Country:US
Mailing Address - Phone:702-420-7704
Mailing Address - Fax:702-420-7704
Practice Address - Street 1:9811 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 2441
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7528
Practice Address - Country:US
Practice Address - Phone:702-953-1576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV13663207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVLL1758OtherNV MEDICAL LIC