Provider Demographics
NPI:1013263847
Name:OMAR A IBRAHIMI MD PHD LLC
Entity Type:Organization
Organization Name:OMAR A IBRAHIMI MD PHD LLC
Other - Org Name:CONNECTICUT SKIN INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:IBRAHIMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-428-4440
Mailing Address - Street 1:2777 SUMMER ST STE 600
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-4323
Mailing Address - Country:US
Mailing Address - Phone:917-301-3781
Mailing Address - Fax:901-221-4916
Practice Address - Street 1:2777 SUMMER ST STE 600
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-4323
Practice Address - Country:US
Practice Address - Phone:203-428-4440
Practice Address - Fax:901-221-4916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2023-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049530207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty