Provider Demographics
NPI:1740256445
Name:BSHARA, IBRAHIM (MD)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:BSHARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20525 CENTER RIDGE RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116
Mailing Address - Country:US
Mailing Address - Phone:440-895-5056
Mailing Address - Fax:440-333-2935
Practice Address - Street 1:3665 W 117TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5215
Practice Address - Country:US
Practice Address - Phone:216-351-0778
Practice Address - Fax:216-251-5963
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063037B207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000031825OtherANTHEM
10789186OtherCAQH
1780634279OtherGROUP NPI
0119204OtherGROUP MEDICAID
3610861OtherGROUP ASC MEDICARE
109285OtherKAISER
CA4511OtherGROUP RR MEDICARE
CA4511OtherRR MEDICARE GROUP
OH0874362Medicaid
110099557OtherRR MEDICARE INDIVIDUAL
9273172OtherGROUP MEDICARE
D368301OtherGROUP IND DIAGNOSTICS MED
CA4511OtherRR MEDICARE GROUP
0119204OtherGROUP MEDICAID
3610861OtherGROUP ASC MEDICARE