Provider Demographics
NPI:1417062712
Name:IBRAHIM, IHAB (MD)
Entity Type:Individual
Prefix:
First Name:IHAB
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IHAB
Other - Middle Name:IBRAHIM GAD
Other - Last Name:IBRAHIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-814-6724
Practice Address - Street 1:1415 E KINCAID ST
Practice Address - Street 2:HOSPITALISTS OFFICE
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4126
Practice Address - Country:US
Practice Address - Phone:360-416-5750
Practice Address - Fax:360-416-5758
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-7946207R00000X
WATD60482949207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1417062712Medicaid
HIF38640Medicare UPIN