Provider Demographics
NPI:1952807711
Name:MOUSA-IBRAHIM, FADY MOHAMMED (DO)
Entity Type:Individual
Prefix:DR
First Name:FADY
Middle Name:MOHAMMED
Last Name:MOUSA-IBRAHIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4106 POLARIS AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-4041
Mailing Address - Country:US
Mailing Address - Phone:510-427-8913
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-2687
Practice Address - Fax:708-216-5617
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program