Provider Demographics
NPI:1407898653
Name:HANNA, IBRAHIM ISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:ISSA
Last Name:HANNA
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 1:640 W. FOOTHILL BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-2403
Mailing Address - Country:US
Mailing Address - Phone:626-335-4041
Mailing Address - Fax:626-335-3768
Practice Address - Street 1:640 W. FOOTHILL BLVD.
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-2403
Practice Address - Country:US
Practice Address - Phone:626-335-4041
Practice Address - Fax:626-335-3768
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50259207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A502591Medicaid
CAP00936005OtherMEDICARE RR
CA110238745OtherMEDICARE RR
CAA50259Medicare PIN
CA00A502591Medicaid
CAF26238Medicare UPIN