Provider Demographics
NPI:1306852934
Name:IBRAHIM, MAGED FAYEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:MAGED
Middle Name:FAYEZ
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 1:6180 CANTABRIA AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-6990
Mailing Address - Country:US
Mailing Address - Phone:693-579-6092
Mailing Address - Fax:
Practice Address - Street 1:16465 SIERRA LAKES PKWY
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-823-8000
Practice Address - Fax:909-823-8088
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076933208000000X
IN01071369A208000000X
CAC141296208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000778133OtherBCBS MEMORIALS CHILDRENS HOSPITAL
IN000000781460OtherBCBS BMG MAIN STREET
IN201079810Medicaid
MI4376460Medicaid
INM400074386Medicare PIN
MI4376460Medicaid