Provider Demographics
NPI:1629621602
Name:ELMUBARAK, IZZELDIN ABDELRAHMAN KHOGALI
Entity Type:Individual
Prefix:
First Name:IZZELDIN
Middle Name:ABDELRAHMAN KHOGALI
Last Name:ELMUBARAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 SELWYN AVE APT 20D
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7689
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7697
Practice Address - Country:US
Practice Address - Phone:646-463-1935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program