Provider Demographics
NPI:1962609222
Name:GHANNAM, IBRAHIM ISAMAIL (DO)
Entity type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:ISAMAIL
Last Name:GHANNAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 W MAHOGANY PL
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-6387
Mailing Address - Country:US
Mailing Address - Phone:480-861-3401
Mailing Address - Fax:480-861-3401
Practice Address - Street 1:1850 N CENTRAL AVE
Practice Address - Street 2:STE 1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4633
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ005544207L00000X
WV2308207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology