Provider Demographics
NPI:1114150257
Name:IBRAHIM, HOMAM
Entity type:Individual
Prefix:
First Name:HOMAM
Middle Name:
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 1:11886 HEALING WAY STE 403
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-7917
Mailing Address - Country:US
Mailing Address - Phone:832-618-6687
Mailing Address - Fax:
Practice Address - Street 1:11886 HEALING WAY STE 403
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7917
Practice Address - Country:US
Practice Address - Phone:832-618-6687
Practice Address - Fax:212-263-8534
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-00985207R00000X
NY284258207RC0000X
NY284258-1207RI0011X
VA0101279579207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1114150257Medicaid
NC1114150257Medicaid