Basic Information
| Provider Information | |||||||||
| NPI: | 1184109209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AWAWDEH | ||||||||
| FirstName: | IBRAHIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2340 KATY LN | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639012300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167673616 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2340 KATY LN | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639012300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732903293 | ||||||||
| FaxNumber: | 6692805057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2018 | ||||||||
| LastUpdateDate: | 08/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2018025505 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | 2018025505 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | 2018025505 | MO | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.