Provider Demographics
NPI:1740462431
Name:QAQISH, IBRAHIM (MD)
Entity type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:
Last Name:QAQISH
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 1:6622 N 91ST AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2569
Mailing Address - Country:US
Mailing Address - Phone:602-759-6883
Mailing Address - Fax:602-224-3358
Practice Address - Street 1:2545 E THOMAS RD
Practice Address - Street 2:SUITE 120
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016
Practice Address - Country:US
Practice Address - Phone:602-419-3378
Practice Address - Fax:602-595-1528
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40440207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ357551Medicaid
AZZ188629Medicare PIN
AZZ130122Medicare PIN