Provider Demographics
NPI:1407899610
Name:JABBOUR, IHSAN I (MD)
Entity Type:Individual
Prefix:DR
First Name:IHSAN
Middle Name:I
Last Name:JABBOUR
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 1:171 GRANDVIEW AVE
Mailing Address - Street 2:SUITE # 105
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2517
Mailing Address - Country:US
Mailing Address - Phone:203-755-2214
Mailing Address - Fax:203-596-1133
Practice Address - Street 1:171 GRANDVIEW AVE
Practice Address - Street 2:SUITE # 105
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2517
Practice Address - Country:US
Practice Address - Phone:203-755-2214
Practice Address - Fax:203-596-1133
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026820207PE0005X, 208600000X, 208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001268200Medicaid
CT010026820CT03OtherBC/BS
FL135799OtherWELLCARE
CTP2041646OtherOXFORD
UT061212173OtherUNITED HEALTH CARE
CT061212173OtherAEBH
CT712173OtherCONNECTICARE
TN061212173 0005OtherCIGNA
CT0R0697OtherPHS
CT0004112221OtherAETNA
CT026820CT NO2OtherCONNECTICARE
UT061212173OtherUNITED HEALTH CARE
FL135799OtherWELLCARE