Provider Demographics
NPI:1588754055
Name:FAHDI, IBRAHIM (MD)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:FAHDI
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:PO BOX 551308
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32255-1308
Mailing Address - Country:US
Mailing Address - Phone:904-622-9040
Mailing Address - Fax:904-309-5691
Practice Address - Street 1:1681 EAGLE HARBOR PKWY STE 101
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003
Practice Address - Country:US
Practice Address - Phone:904-644-0092
Practice Address - Fax:904-644-0099
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113759207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006622500Medicaid
ARP00165055OtherRAILROAD MEDICARE
AL1588754055Medicaid
FLGP557ZMedicare PIN
ARP00165055OtherRAILROAD MEDICARE