Provider Demographics
NPI:1053846790
Name:IBRAHIM, MARYANNE ROSE (MD)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:ROSE
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17360 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:714-665-4614
Mailing Address - Fax:
Practice Address - Street 1:17360 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3720
Practice Address - Country:US
Practice Address - Phone:714-665-4614
Practice Address - Fax:714-665-1797
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA171435207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program