Provider Demographics
NPI:1265814628
Name:SERHAN, MUSTAPHA IBRAHIM (MD)
Entity Type:Individual
Prefix:DR
First Name:MUSTAPHA
Middle Name:IBRAHIM
Last Name:SERHAN
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 1:6040 S FORT APACHE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5613
Mailing Address - Country:US
Mailing Address - Phone:702-476-4900
Mailing Address - Fax:
Practice Address - Street 1:6040 S FORT APACHE RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5613
Practice Address - Country:US
Practice Address - Phone:702-476-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20823207RH0002X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV20823OtherNV MEDICAL LICENSE
NV1265814628Medicaid