Provider Demographics
NPI:1619918760
Name:IBRAHIM, HISHAM IZZADIN (MD)
Entity Type:Individual
Prefix:
First Name:HISHAM
Middle Name:IZZADIN
Last Name:IBRAHIM
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 1:3333 E CAMELBACK RD
Mailing Address - Street 2:STE 180
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2396
Mailing Address - Country:US
Mailing Address - Phone:602-759-6883
Mailing Address - Fax:602-224-3315
Practice Address - Street 1:1210 E PLANT ST STE 120
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-2995
Practice Address - Country:US
Practice Address - Phone:407-297-8408
Practice Address - Fax:407-297-8408
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17166207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME114722OtherLICENSE
NV1619918760Medicaid