Provider Demographics
NPI:1881006120
Name:IBRAHIM, AHMAD
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:
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 7215
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90406-7215
Mailing Address - Country:US
Mailing Address - Phone:661-222-9117
Mailing Address - Fax:888-278-0126
Practice Address - Street 1:24159 MAGIC MOUNTAIN PKWY
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-3904
Practice Address - Country:US
Practice Address - Phone:661-222-9117
Practice Address - Fax:888-278-0126
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16622207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program