Provider Demographics
NPI:1114150257
Name:IBRAHIM, HOMAM
Entity Type:Individual
Prefix:
First Name:HOMAM
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 1ST AVE FL 14
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-5656
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE FL 14
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-263-5656
Practice Address - Fax:212-263-8534
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00985207R00000X
NY284258207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1114150257Medicaid
NC1114150257Medicaid