Provider Demographics
NPI:1033685755
Name:IBRAHIM, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 VIEWCREST CT
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-8908
Mailing Address - Country:US
Mailing Address - Phone:347-817-0674
Mailing Address - Fax:
Practice Address - Street 1:1120 VIEWCREST CT
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-8908
Practice Address - Country:US
Practice Address - Phone:347-817-0674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist