Provider Demographics
NPI:1598841819
Name:GHEBRAI, RUSSOM BARIAGHABER (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSOM
Middle Name:BARIAGHABER
Last Name:GHEBRAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10533 PENNYDOG LN
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-4161
Mailing Address - Country:US
Mailing Address - Phone:301-502-6912
Mailing Address - Fax:
Practice Address - Street 1:1310 SOUTHERN AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4623
Practice Address - Country:US
Practice Address - Phone:202-574-7077
Practice Address - Fax:202-574-7156
Is Sole Proprietor?:No
Enumeration Date:2006-10-29
Last Update Date:2015-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD035237207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCI22192Medicare UPIN