Provider Demographics
NPI:1154673713
Name:IBRAHIM, WALEED (MD)
Entity Type:Individual
Prefix:
First Name:WALEED
Middle Name:
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 1:4723 COMMONS DR
Mailing Address - Street 2:APT 304
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-5066
Mailing Address - Country:US
Mailing Address - Phone:760-444-3076
Mailing Address - Fax:
Practice Address - Street 1:4723 COMMONS DR
Practice Address - Street 2:APT 304
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-5066
Practice Address - Country:US
Practice Address - Phone:760-444-3076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010729462085R0202X
NC2003008152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology