Provider Demographics
NPI:1063451771
Name:IBRAHIM, MAHMOUD ALI (MD)
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:ALI
Last Name:IBRAHIM
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 1:7974 HAVEN AVE
Mailing Address - Street 2:STE. 290
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3052
Mailing Address - Country:US
Mailing Address - Phone:909-944-5553
Mailing Address - Fax:909-944-3339
Practice Address - Street 1:7974 HAVEN AVE
Practice Address - Street 2:STE. 290
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3052
Practice Address - Country:US
Practice Address - Phone:909-944-5553
Practice Address - Fax:909-944-3339
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42803208000000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F34530Medicare UPIN