Provider Demographics
NPI:1184081432
Name:SAMUEL IBRAHIM, MD, INC
Entity type:Organization
Organization Name:SAMUEL IBRAHIM, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IBRAHIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-241-3033
Mailing Address - Street 1:79180 CORPORATE CENTER DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-7235
Mailing Address - Country:US
Mailing Address - Phone:760-837-7910
Mailing Address - Fax:760-837-7920
Practice Address - Street 1:79180 CORPORATE CENTER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7235
Practice Address - Country:US
Practice Address - Phone:760-837-7910
Practice Address - Fax:760-837-7920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA120880208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty