Provider Demographics
NPI:1215906458
Name:IBRAHEEM, MONSURU O (MD)
Entity type:Individual
Prefix:DR
First Name:MONSURU
Middle Name:O
Last Name:IBRAHEEM
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 1:6970 W. PATRICK LANE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-0270
Mailing Address - Country:US
Mailing Address - Phone:702-450-1717
Mailing Address - Fax:702-947-6740
Practice Address - Street 1:6970 W. PATRICK LANE
Practice Address - Street 2:SUITE 140
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-0270
Practice Address - Country:US
Practice Address - Phone:702-450-1717
Practice Address - Fax:702-947-6740
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2328501208M00000X, 207R00000X
NV11842207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02592047Medicaid
I18202Medicare UPIN
RA4614Medicare ID - Type Unspecified