Provider Demographics
NPI:1720007032
Name:IBRAHIM, GEORGE (PT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:B2 BRIER HILL CT
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3348
Mailing Address - Country:US
Mailing Address - Phone:732-967-1000
Mailing Address - Fax:732-967-1500
Practice Address - Street 1:B2 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3348
Practice Address - Country:US
Practice Address - Phone:732-967-1000
Practice Address - Fax:732-967-1500
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA01135800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ091785Medicare ID - Type Unspecified