Provider Demographics
NPI:1912494279
Name:IBRAHIMI, KHURSHID
Entity Type:Individual
Prefix:
First Name:KHURSHID
Middle Name:
Last Name:IBRAHIMI
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 1:59 MARTIN RD N
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-5119
Mailing Address - Country:US
Mailing Address - Phone:516-680-5484
Mailing Address - Fax:
Practice Address - Street 1:59 MARTIN RD N
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5119
Practice Address - Country:US
Practice Address - Phone:516-680-5484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-21
Last Update Date:2018-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041567225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist