Provider Demographics
NPI:1073984985
Name:AZRAG, IBRAHIM
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:AZRAG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:IBRAHIM
Other - Middle Name:SILIK
Other - Last Name:AZRAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3120 SHADY TREE LN
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-2482
Mailing Address - Country:US
Mailing Address - Phone:615-585-3778
Mailing Address - Fax:206-888-4011
Practice Address - Street 1:3120 SHADY TREE LN
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-2482
Practice Address - Country:US
Practice Address - Phone:615-585-3778
Practice Address - Fax:206-888-4011
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN189601172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver