Provider Demographics
NPI:1417337353
Name:IBRAHIM, HAZIM (DPM)
Entity Type:Individual
Prefix:DR
First Name:HAZIM
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7527 THOROUGHBRED DR APT 3D
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2362
Mailing Address - Country:US
Mailing Address - Phone:408-403-6924
Mailing Address - Fax:
Practice Address - Street 1:7527 THOROUGHBRED DR APT 3D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:440-840-3692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001283A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty