Provider Demographics
NPI:1477308955
Name:IBRAHIM, SHENOUDA
Entity Type:Individual
Prefix:
First Name:SHENOUDA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4244 BROAD HILL DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7819
Mailing Address - Country:US
Mailing Address - Phone:551-358-6111
Mailing Address - Fax:
Practice Address - Street 1:4244 BROAD HILL DR UNIT A
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-7819
Practice Address - Country:US
Practice Address - Phone:551-358-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program