Provider Demographics
NPI:1992305890
Name:ELLITHY, IBRAHIM (CPO)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:ELLITHY
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17431 N 83RD DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-8083
Mailing Address - Country:US
Mailing Address - Phone:623-302-0919
Mailing Address - Fax:
Practice Address - Street 1:10615 W THUNDERBIRD BLVD STE D165
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3033
Practice Address - Country:US
Practice Address - Phone:623-977-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist