Provider Demographics
NPI:1760641906
Name:IBRAHIM, GAMAL S (PT)
Entity Type:Individual
Prefix:MR
First Name:GAMAL
Middle Name:S
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 1:6706 BLUE POINT DR
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-3419
Mailing Address - Country:US
Mailing Address - Phone:760-814-4207
Mailing Address - Fax:
Practice Address - Street 1:6706 BLUE POINT DR
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-3419
Practice Address - Country:US
Practice Address - Phone:760-814-4207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02099F225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA02099FOtherPT LICENSE