Provider Demographics
NPI:1437154630
Name:ABDALLA, IBRAHIM (MD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:
Last Name:ABDALLA
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:PO BOX 9007
Mailing Address - Street 2:STE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-269-8926
Mailing Address - Fax:417-269-5371
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:STE 100
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-269-8926
Practice Address - Fax:417-269-5371
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000158663174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO148380070OtherMEDICARE PTAN
MO205070303Medicaid
MOF81178Medicare UPIN
MO205070303Medicaid