Provider Demographics
NPI:1437368669
Name:IBRAHIM, MAMDOUH SAYED (PTA)
Entity Type:Individual
Prefix:
First Name:MAMDOUH
Middle Name:SAYED
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-2209
Mailing Address - Country:US
Mailing Address - Phone:201-339-5185
Mailing Address - Fax:
Practice Address - Street 1:221 COUNTY RD
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-1605
Practice Address - Country:US
Practice Address - Phone:201-567-9310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQB1281225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant