Provider Demographics
NPI:1427110717
Name:IBRAHIM, M A ZURITA HERNANDO (PT)
Entity type:Individual
Prefix:MRS
First Name:M A ZURITA
Middle Name:HERNANDO
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WASHINGTON STREET
Mailing Address - Street 2:PO BOX 536
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164
Mailing Address - Country:US
Mailing Address - Phone:304-273-8071
Mailing Address - Fax:304-273-8015
Practice Address - Street 1:240 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164
Practice Address - Country:US
Practice Address - Phone:304-273-8071
Practice Address - Fax:304-273-8015
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0157410000Medicaid
WV0240071000Medicaid
WV0157410000Medicaid
MA9331861Medicare ID - Type UnspecifiedINDIVIDUAL ID#