Provider Demographics
NPI:1508061128
Name:IBRAHIMI, OMAR A (MD, PHD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:A
Last Name:IBRAHIMI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 SUMMER ST
Mailing Address - Street 2:STE 305
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5513
Mailing Address - Country:US
Mailing Address - Phone:203-428-4440
Mailing Address - Fax:203-890-9449
Practice Address - Street 1:2777 SUMMER ST STE 600
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-4323
Practice Address - Country:US
Practice Address - Phone:203-428-4440
Practice Address - Fax:901-221-4916
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAL-232692207N00000X
CT049530207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1508061128Medicaid