Provider Demographics
NPI:1376852111
Name:ELMUBARAK, MARWAN GAMAL
Entity Type:Individual
Prefix:MR
First Name:MARWAN
Middle Name:GAMAL
Last Name:ELMUBARAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 E LOMA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2926
Mailing Address - Country:US
Mailing Address - Phone:480-861-6490
Mailing Address - Fax:
Practice Address - Street 1:2022 E LOMA VISTA DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2926
Practice Address - Country:US
Practice Address - Phone:480-861-6490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ463999171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ463999OtherARIZONA HEALTH CARE COST CONTAINMENT SYSTEM