Provider Demographics
NPI:1326258385
Name:DIALLO, IBRAHIMA (PT)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIMA
Middle Name:
Last Name:DIALLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 GREENBELT RD
Mailing Address - Street 2:E-347
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2255
Mailing Address - Country:US
Mailing Address - Phone:301-446-1724
Mailing Address - Fax:301-446-1726
Practice Address - Street 1:7315 HANOVER PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2035
Practice Address - Country:US
Practice Address - Phone:301-446-1724
Practice Address - Fax:301-446-1726
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC870275225100000X
MD19812225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD442144200Medicaid
MD412134682OtherTAX #
MD510203102Medicaid
MDG01610I01Medicare ID - Type UnspecifiedPT MARYLAND
DC09-6503Medicare Oscar/Certification