Provider Demographics
NPI:1518056464
Name:ISMAIL, ANJUM
Entity Type:Individual
Prefix:
First Name:ANJUM
Middle Name:
Last Name:ISMAIL
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 1:2641 W HORIZON RIDGE PKWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4830
Mailing Address - Country:US
Mailing Address - Phone:701-616-0091
Mailing Address - Fax:702-616-2329
Practice Address - Street 1:2641 W HORIZON RIDGE PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4830
Practice Address - Country:US
Practice Address - Phone:701-616-0091
Practice Address - Fax:702-616-2329
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9344207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018663Medicaid
G93144Medicare UPIN
NV002018663Medicaid