Provider Demographics
NPI:1285851758
Name:ABU-USBAABDEL-FATTAH, IBRAHIM
Entity Type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:ABU-USBAABDEL-FATTAH
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:P O BOX 270161
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00927
Mailing Address - Country:US
Mailing Address - Phone:787-735-7969
Mailing Address - Fax:
Practice Address - Street 1:C JOSE C VAZQUEZ INT
Practice Address - Street 2:
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-735-7969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11946208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
G40977Medicare UPIN
87818Medicare ID - Type Unspecified