Basic Information
| Provider Information | |||||||||
| NPI: | 1730567108 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MABROOK L. SHEHATA MD MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2660 CRIMSON CANYON DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613278000 | ||||||||
| FaxNumber: | 6613278020 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 S OAK AVE | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953613519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2015 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHEHATA | ||||||||
| AuthorizedOfficialFirstName: | MABROOK | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5625771098 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.