Provider Demographics
NPI:1063658334
Name:STEVE IBRAHIM DO PLLC
Entity Type:Organization
Organization Name:STEVE IBRAHIM DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:I
Authorized Official - Credentials:DO
Authorized Official - Phone:602-361-3593
Mailing Address - Street 1:20118 N 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4621
Mailing Address - Country:US
Mailing Address - Phone:602-361-3593
Mailing Address - Fax:
Practice Address - Street 1:4065 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2208
Practice Address - Country:US
Practice Address - Phone:602-867-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4396314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
I59415Medicare UPIN