Provider Demographics
NPI:1194768549
Name:IBRAHIM, MIRIAM LELA (MD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:LELA
Last Name:IBRAHIM
Suffix:
Gender:F
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:PO BOX 1889
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47308-1889
Mailing Address - Country:US
Mailing Address - Phone:765-284-0493
Mailing Address - Fax:
Practice Address - Street 1:1107 S TILLOTSON AVE
Practice Address - Street 2:STE 1
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4517
Practice Address - Country:US
Practice Address - Phone:765-213-3024
Practice Address - Fax:765-282-9303
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047444A208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20174740Medicaid
IN20174740Medicaid
INM400062507Medicare PIN
G73258Medicare UPIN