Provider Demographics
NPI:1821056516
Name:IBNERASA, HASIB (MD)
Entity Type:Individual
Prefix:
First Name:HASIB
Middle Name:
Last Name:IBNERASA
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:PO BOX 953457
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32795-3457
Mailing Address - Country:US
Mailing Address - Phone:407-936-0976
Mailing Address - Fax:407-936-0977
Practice Address - Street 1:2500 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3501
Practice Address - Country:US
Practice Address - Phone:407-936-0976
Practice Address - Fax:407-936-0977
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262539300Medicaid
FLE6728ZMedicare PIN
FL262539300Medicaid