Provider Demographics
NPI:1952370710
Name:IBRAHIM, MAZEN M
Entity Type:Individual
Prefix:DR
First Name:MAZEN
Middle Name:M
Last Name:IBRAHIM
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 1:9423 HIGHWAY 403
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-9664
Mailing Address - Country:US
Mailing Address - Phone:812-256-6388
Mailing Address - Fax:812-256-0475
Practice Address - Street 1:9423 HIGHWAY 403
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-9664
Practice Address - Country:US
Practice Address - Phone:812-256-6388
Practice Address - Fax:812-256-0475
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028371A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100075220Medicaid
IN000000042374OtherANTHEM
IN100075220Medicaid
IN260810BMedicare PIN
IN000000042374OtherANTHEM