Provider Demographics
NPI:1053388090
Name:MABOURAKH, SHAHRAD (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHRAD
Middle Name:
Last Name:MABOURAKH
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 1:6451 W COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-2110
Mailing Address - Country:US
Mailing Address - Phone:954-720-1414
Mailing Address - Fax:954-720-4727
Practice Address - Street 1:6451 W COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-2110
Practice Address - Country:US
Practice Address - Phone:954-720-1414
Practice Address - Fax:954-720-4727
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067283207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26685ZMedicare PIN
F08889Medicare UPIN