Provider Demographics
NPI:1134675218
Name:IBRAHIM, JOHN FIKRY MITYAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:FIKRY MITYAS
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 1:11S513 RACHAEL CT
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6899
Mailing Address - Country:US
Mailing Address - Phone:331-214-1843
Mailing Address - Fax:
Practice Address - Street 1:11S513 RACHAEL CT
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-6899
Practice Address - Country:US
Practice Address - Phone:331-214-1843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-29
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125069705207R00000X
IL036147616207R00000X, 208M00000X
WI1018-320208M00000X
FLME151077208M00000X
IN01084871A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine