Provider Demographics
NPI:1972947547
Name:IBRAHIM, KAYODE
Entity Type:Individual
Prefix:
First Name:KAYODE
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 1:4110 71ST AVE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2622
Mailing Address - Country:US
Mailing Address - Phone:301-237-0350
Mailing Address - Fax:
Practice Address - Street 1:439 ONEIDA PL NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-2150
Practice Address - Country:US
Practice Address - Phone:202-291-7922
Practice Address - Fax:202-291-4009
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC036061400Medicaid