Provider Demographics
NPI:1467465724
Name:IBRAHIM, IBRAHIM M (MD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:M
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 1:350 ENGLE ST
Mailing Address - Street 2:2 EAST
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1808
Mailing Address - Country:US
Mailing Address - Phone:201-227-5533
Mailing Address - Fax:201-227-5537
Practice Address - Street 1:350 ENGLE ST
Practice Address - Street 2:2 EAST
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:201-227-5533
Practice Address - Fax:201-227-5537
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ193400000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0756709Medicaid
NJ0756709Medicaid
NJ050411U89Medicare PIN
050411U89Medicare ID - Type Unspecified