Provider Demographics
NPI:1871765727
Name:WEST BROWARD INTERNAL MEDICINE PLLC
Entity type:Organization
Organization Name:WEST BROWARD INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MABOURAKH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-720-1414
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67283207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF08889Medicare UPIN
FLAJ401Medicare PIN
FLY2811YMedicare PIN