Provider Demographics
NPI:1184367245
Name:IBRAHIM, MARYAM KHALID (MD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:KHALID
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARYAM
Other - Middle Name:KHALID
Other - Last Name:IBRAHIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPH , MD
Mailing Address - Street 1:75 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2190
Mailing Address - Country:US
Mailing Address - Phone:312-515-2128
Mailing Address - Fax:631-686-7651
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2190
Practice Address - Country:US
Practice Address - Phone:631-686-2549
Practice Address - Fax:631-686-7651
Is Sole Proprietor?:No
Enumeration Date:2022-04-17
Last Update Date:2022-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program