Provider Demographics
NPI:1356523385
Name:BERMUDAS, JIBRIALLAH
Entity type:Individual
Prefix:
First Name:JIBRIALLAH
Middle Name:
Last Name:BERMUDAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 IVEY PARK LN
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4786
Mailing Address - Country:US
Mailing Address - Phone:770-912-2491
Mailing Address - Fax:
Practice Address - Street 1:1197 BEAVER RUIN RD STE 102
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-6802
Practice Address - Country:US
Practice Address - Phone:770-912-2491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No175M00000XOther Service ProvidersMidwife, Lay