Provider Demographics
NPI:1740858380
Name:ELKHAWAS, IBRAHIM
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:ELKHAWAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CROWN DR UNIT 103
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 DORCHESTER AVE RM 7039
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02124-5615
Practice Address - Country:US
Practice Address - Phone:502-232-5956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA289311207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine