Provider Demographics
NPI:1528214533
Name:ELFADIL, IBRAHIM EM JR (SA-C)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:EM
Last Name:ELFADIL
Suffix:JR
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:IBRAHIM
Other - Middle Name:EM
Other - Last Name:ELFADIL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SA-C
Mailing Address - Street 1:13305 HUNTINGTON LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5130
Mailing Address - Country:US
Mailing Address - Phone:571-572-8176
Mailing Address - Fax:
Practice Address - Street 1:13305 HUNTINGTON LN
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193
Practice Address - Country:US
Practice Address - Phone:571-572-8176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-09
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA153122918018Medicaid