1780625376 NPI number — DR. DINA IBRAHIM M.D

Table of content: DR. DINA IBRAHIM M.D (NPI 1780625376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780625376 NPI number — DR. DINA IBRAHIM M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IBRAHIM
Provider First Name:
DINA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
IBRAHIM
Provider Other First Name:
DINA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1780625376
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7065 N. MAPLE AVE
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-554-2100
Provider Business Mailing Address Fax Number:
559-554-2114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7065 N. MAPLE
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-554-2100
Provider Business Practice Location Address Fax Number:
559-554-2114
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X , with the licence number:  C51181 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4668885 . This is a "ECFMG" identifier . This identifiers is of the category "OTHER".
  • Identifier: CA1866078 . This is a "INDIVIDUAL MEDICARE PTAN NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ37565Z . This is a "GROUP PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: C51181 . This is a "CALIF. MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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