Provider Demographics
NPI:1295081198
Name:IBRAHIM, MOHAMMAD (DO)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9304 AUTUMN BROOKE WAY
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-0943
Mailing Address - Country:US
Mailing Address - Phone:516-305-1454
Mailing Address - Fax:
Practice Address - Street 1:9304 AUTUMN BROOKE WAY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-0943
Practice Address - Country:US
Practice Address - Phone:516-305-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-28
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine