Provider Demographics
NPI:1811983232
Name:IBRAHEEM, LAJA I (MD)
Entity type:Individual
Prefix:
First Name:LAJA
Middle Name:I
Last Name:IBRAHEEM
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:PO BOX 20140
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90801-3140
Mailing Address - Country:US
Mailing Address - Phone:562-637-3143
Mailing Address - Fax:562-637-3244
Practice Address - Street 1:4000 LONG BEACH BLVD
Practice Address - Street 2:SUITE 228
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2617
Practice Address - Country:US
Practice Address - Phone:562-637-3143
Practice Address - Fax:562-637-3244
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA661242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A661240Medicaid
CA00A661240Medicaid
H08638Medicare UPIN