Provider Demographics
NPI:1891347738
Name:HAJJALI, IBRAHIM RAEF (MD, MSC)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:RAEF
Last Name:HAJJALI
Suffix:
Gender:M
Credentials:MD, MSC
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 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:626-457-6601
Mailing Address - Fax:
Practice Address - Street 1:1441 EASTLAKE AVE STE 2424K
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-1020
Practice Address - Country:US
Practice Address - Phone:626-689-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2023-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL.0006862390200000X
CAA186520207ZC0006X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology