Provider Demographics
NPI:1518216704
Name:IBRAHIM, SAMAR MOHAMED
Entity Type:Individual
Prefix:
First Name:SAMAR
Middle Name:MOHAMED
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18902 64TH AVE
Mailing Address - Street 2:7B
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3853
Mailing Address - Country:US
Mailing Address - Phone:646-472-6741
Mailing Address - Fax:
Practice Address - Street 1:18902 64TH AVE
Practice Address - Street 2:7B
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-3853
Practice Address - Country:US
Practice Address - Phone:646-472-6741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-03
Last Update Date:2012-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist