Basic Information
| Provider Information | |||||||||
| NPI: | 1740456136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBRAHIM | ||||||||
| FirstName: | GHASSAN | ||||||||
| MiddleName: | JERJOUS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 42210 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850802210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6232667770 | ||||||||
| FaxNumber: | 6233224639 | ||||||||
| Practice Location | |||||||||
| Address1: | 424 S 56TH ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850342177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026855166 | ||||||||
| FaxNumber: | 6026855325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 25MA08776200 | NJ | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 58135 | AZ | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.