Provider Demographics
NPI:1346814761
Name:MOHAMMED, IBRAHEAM
Entity type:Individual
Prefix:
First Name:IBRAHEAM
Middle Name:
Last Name:MOHAMMED
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 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-478-4206
Mailing Address - Fax:260-478-3628
Practice Address - Street 1:7916 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-478-4206
Practice Address - Fax:260-478-3628
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02007837A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program