Provider Demographics
NPI:1730691890
Name:ABRAHAM T. FAKHOURI, M.D.
Entity type:Organization
Organization Name:ABRAHAM T. FAKHOURI, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:FAKHOURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-933-1485
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:
Mailing Address - Fax:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV20171542901OtherSOS BUSINESS LICENSE