Provider Demographics
NPI:1255913950
Name:GARIEBALLA, AHMED ISAM (MBBS)
Entity type:Individual
Prefix:
First Name:AHMED
Middle Name:ISAM
Last Name:GARIEBALLA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1018
Mailing Address - Country:US
Mailing Address - Phone:510-437-5039
Mailing Address - Fax:510-535-7313
Practice Address - Street 1:1411 E 31ST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1018
Practice Address - Country:US
Practice Address - Phone:510-437-5039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA192700282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program