Provider Demographics
NPI:1992725048
Name:IBRAHIM, MOHAMMAD (MD)
Entity type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:IBRAHIM
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 1:19101 CORTEZ BLVD STE 10065
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3013
Mailing Address - Country:US
Mailing Address - Phone:352-573-0240
Mailing Address - Fax:352-606-5723
Practice Address - Street 1:19101 CORTEZ BLVD STE 10065
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3013
Practice Address - Country:US
Practice Address - Phone:352-325-9294
Practice Address - Fax:352-606-5723
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJME0095660207R00000X
FLME95660208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275431200Medicaid
FLU8479XMedicare PIN
FLU8479YMedicare PIN