Provider Demographics
NPI:1962187914
Name:IBRAHIM, IBRAHIM MOHAMUD
Entity type:Individual
Prefix:MR
First Name:IBRAHIM
Middle Name:MOHAMUD
Last Name:IBRAHIM
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 1:725 W LAPHAM BLVD APT 11
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3446
Mailing Address - Country:US
Mailing Address - Phone:716-431-0218
Mailing Address - Fax:
Practice Address - Street 1:725 W LAPHAM BLVD APT 11
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3446
Practice Address - Country:US
Practice Address - Phone:716-431-0218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WII1654139547107172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Multi-Specialty