Provider Demographics
NPI:1043488216
Name:IBRAHIM, MOHAMED GHONIEM (PT)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:GHONIEM
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 HIGHWAY 466
Mailing Address - Street 2:SUITE A
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-3792
Mailing Address - Country:US
Mailing Address - Phone:352-787-0669
Mailing Address - Fax:
Practice Address - Street 1:607 HIGHWAY 466
Practice Address - Street 2:SUITE A
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-3792
Practice Address - Country:US
Practice Address - Phone:352-787-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 12757174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT 12757OtherPT LIC