Provider Demographics
NPI:1376048215
Name:INNAB, IBRAHEEM R (MD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHEEM
Middle Name:R
Last Name:INNAB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:677 CHURCH ST NE # 111
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1101
Mailing Address - Country:US
Mailing Address - Phone:770-793-7750
Mailing Address - Fax:770-793-7755
Practice Address - Street 1:677 CHURCH ST NE # 111
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-793-7750
Practice Address - Fax:770-793-7755
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA89100208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program