Provider Demographics
NPI:1154379295
Name:IBRAHIM, MOHAMED M (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:M
Last Name:IBRAHIM
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 1:15 ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5226
Mailing Address - Country:US
Mailing Address - Phone:716-341-3983
Mailing Address - Fax:716-433-6388
Practice Address - Street 1:15 ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5226
Practice Address - Country:US
Practice Address - Phone:716-341-3983
Practice Address - Fax:716-433-6388
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087769208600000X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02836482Medicaid
NY02836482Medicaid