Provider Demographics
NPI:1235309527
Name:IBRAHIM, MOHAMED RUZAIK (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMED RUZAIK
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 1:4113 S WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6293
Mailing Address - Country:US
Mailing Address - Phone:618-315-6090
Mailing Address - Fax:618-204-5472
Practice Address - Street 1:4115 S WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6293
Practice Address - Country:US
Practice Address - Phone:618-315-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98494207R00000X
IL036128960207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine