Basic Information
| Provider Information | |||||||||
| NPI: | 1659331387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ONBIRBAK | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | BEHNAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1995 ALCOVA RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891351551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023832691 | ||||||||
| FaxNumber: | 7023884114 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 S RANCHO DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891024506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023832691 | ||||||||
| FaxNumber: | 4023884114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 7161 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 25730 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 12-02877/001102877 | 05 | NV | MEDICAID |