Provider Demographics
NPI:1063404663
Name:IMTIAZ, FARRUKH (MD)
Entity type:Individual
Prefix:
First Name:FARRUKH
Middle Name:
Last Name:IMTIAZ
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 1:3650 S EASTERN AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-3379
Mailing Address - Country:US
Mailing Address - Phone:702-933-6768
Mailing Address - Fax:702-933-6770
Practice Address - Street 1:3650 S EASTERN AVE
Practice Address - Street 2:STE 210
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-3345
Practice Address - Country:US
Practice Address - Phone:702-933-6768
Practice Address - Fax:702-933-6770
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9523207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0002018400Medicaid
NVH26726Medicare UPIN
33927Medicare PIN