Provider Demographics
NPI:1699722827
Name:ABDALLA WAFIK, IBRAHIM AHMED (MD)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:AHMED
Last Name:ABDALLA WAFIK
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:875 STERTHAUS AVE
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5131
Practice Address - Country:US
Practice Address - Phone:386-676-0255
Practice Address - Fax:386-676-2555
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.23353207R00000X
FLME71172174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251018900Medicaid
FLG39245Medicare UPIN
FL251018900Medicaid