Provider Demographics
NPI:1740364926
Name:IBRAHIM, NIZAR ISA (MD)
Entity type:Individual
Prefix:DR
First Name:NIZAR
Middle Name:ISA
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 1:25285 JACLYN AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-5707
Mailing Address - Country:US
Mailing Address - Phone:951-243-1165
Mailing Address - Fax:
Practice Address - Street 1:24490 SUNNYMEAD BLVD
Practice Address - Street 2:STE 117
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-7734
Practice Address - Country:US
Practice Address - Phone:951-242-9595
Practice Address - Fax:951-247-2577
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A703100Medicaid
BI6620923OtherDEA CERTIFICATE
BI6620923OtherDEA CERTIFICATE
CA00A703100Medicaid