Basic Information
| Provider Information | |||||||||
| NPI: | 1275568883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETEBAR | ||||||||
| FirstName: | RAMIN | ||||||||
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| Credential: | MD LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 W. CHARLESTON BLVD. STE. 508 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023832688 | ||||||||
| FaxNumber: | 7026716595 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 MARKS ST. | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023836210 | ||||||||
| FaxNumber: | 7024357050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 10/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 6788 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 002019316 | 05 | NV | MEDICAID |