Provider Demographics
NPI:1780647321
Name:IBRAHIM, AHMED RAZA (MD)
Entity Type:Individual
Prefix:
First Name:AHMED
Middle Name:RAZA
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 1:900 ELKRIDGE LANDING RD FL 2
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2924
Mailing Address - Country:US
Mailing Address - Phone:443-462-5010
Mailing Address - Fax:
Practice Address - Street 1:7601 OSLER DR
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204
Practice Address - Country:US
Practice Address - Phone:410-337-1150
Practice Address - Fax:410-337-1844
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD75502207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200814620Medicaid
I51107Medicare UPIN
IN207070IMedicare PIN