Provider Demographics
NPI:1376611251
Name:IBRAHIM, FAHIM K (MD)
Entity Type:Individual
Prefix:
First Name:FAHIM
Middle Name:K
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 1:4190 24TH AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3882
Mailing Address - Country:US
Mailing Address - Phone:810-989-7702
Mailing Address - Fax:810-989-7703
Practice Address - Street 1:4190 24TH AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3882
Practice Address - Country:US
Practice Address - Phone:810-989-7702
Practice Address - Fax:810-989-7703
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIFI067033207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3350530Medicaid
MI3350530Medicaid
E18704Medicare UPIN