Provider Demographics
NPI:1720248206
Name:FAKHOURI, IBRAHIM TAWFIQ (MD)
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:TAWFIQ
Last Name:FAKHOURI
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 1:861 CORONADO CENTER DR STE 220
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-3992
Mailing Address - Country:US
Mailing Address - Phone:702-933-1485
Mailing Address - Fax:702-933-1490
Practice Address - Street 1:861 CORONADO CENTER DR STE 220
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3992
Practice Address - Country:US
Practice Address - Phone:702-933-1485
Practice Address - Fax:702-933-1490
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2010-0739207Q00000X
FLME 109981207Q00000X
PAMD443512207Q00000X
NV14038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine