Basic Information
| Provider Information | |||||||||
| NPI: | 1063464865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBARRA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 166474 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331166474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558266460 | ||||||||
| FaxNumber: | 7726213184 | ||||||||
| Practice Location | |||||||||
| Address1: | 3663 S MIAMI AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331334253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058544400 | ||||||||
| FaxNumber: | 3052855068 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 162320-1 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01911884 | 05 | NY | MEDICAID |