Basic Information
| Provider Information | |||||||||
| NPI: | 1184367245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBRAHIM | ||||||||
| FirstName: | MARYAM | ||||||||
| MiddleName: | KHALID | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IBRAHIM | ||||||||
| OtherFirstName: | MARYAM | ||||||||
| OtherMiddleName: | KHALID | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MPH , MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 75 N COUNTRY RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125152128 | ||||||||
| FaxNumber: | 6316867651 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 N COUNTRY RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316862549 | ||||||||
| FaxNumber: | 6316867651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2022 | ||||||||
| LastUpdateDate: | 04/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.