Provider Demographics
NPI:1124015508
Name:IBRAHIM, MIAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:MIAN
Middle Name:A
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:PO BOX 53127
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3127
Mailing Address - Country:US
Mailing Address - Phone:337-261-7970
Mailing Address - Fax:
Practice Address - Street 1:1214 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2621
Practice Address - Country:US
Practice Address - Phone:337-261-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA245482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1486914Medicaid
LA5H902Medicare PIN
LAH28282Medicare UPIN
LA1486914Medicaid