Provider Demographics
NPI:1558405647
Name:IBRAHIM, CECILIA (MD)
Entity Type:Individual
Prefix:DR
First Name:CECILIA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
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:P.O. BOX 550
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443
Mailing Address - Country:US
Mailing Address - Phone:708-460-3300
Mailing Address - Fax:708-460-3301
Practice Address - Street 1:10749 W 159TH ST
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-4531
Practice Address - Country:US
Practice Address - Phone:708-460-3300
Practice Address - Fax:708-460-3301
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36090846207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG41930Medicare UPIN