Provider Demographics
NPI:1851301220
Name:SIDHOM, IBRAHIM WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:WILLIAM
Last Name:SIDHOM
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 1:48 PULASKI AVE
Mailing Address - Street 2:
Mailing Address - City:CARTERET
Mailing Address - State:NJ
Mailing Address - Zip Code:07008-2509
Mailing Address - Country:US
Mailing Address - Phone:732-541-5595
Mailing Address - Fax:732-541-1451
Practice Address - Street 1:48 PULASKI AVE
Practice Address - Street 2:
Practice Address - City:CARTERET
Practice Address - State:NJ
Practice Address - Zip Code:07008-2509
Practice Address - Country:US
Practice Address - Phone:732-541-5595
Practice Address - Fax:732-541-1451
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA50525207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7530803Medicaid
F82827Medicare UPIN
007317Medicare ID - Type Unspecified