Provider Demographics
NPI:1407901135
Name:IBRAHIM, MAGUED (MD)
Entity Type:Individual
Prefix:
First Name:MAGUED
Middle Name:
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 1:2836 ENTERPRISE RD
Mailing Address - Street 2:SUITE # 4
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-5210
Mailing Address - Country:US
Mailing Address - Phone:386-951-4538
Mailing Address - Fax:386-259-3689
Practice Address - Street 1:2836 ENTERPRISE RD
Practice Address - Street 2:SUITE #4
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-5210
Practice Address - Country:US
Practice Address - Phone:386-951-4538
Practice Address - Fax:386-259-3689
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME944332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05145OtherBCBS OF FL
FL001062300Medicaid
FL05145OtherBCBS OF FL