1073728259 NPI number — IBRAHIM N. OUDEH MD PA

Table of content: (NPI 1073728259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073728259 NPI number — IBRAHIM N. OUDEH MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IBRAHIM N. OUDEH MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073728259
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 TILGHMAN DR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUNN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28334-4958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-892-6500
Provider Business Mailing Address Fax Number:
910-892-1031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 TILGHMAN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUNN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-292-2070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OUDEH
Authorized Official First Name:
IBRAHIM
Authorized Official Middle Name:
N
Authorized Official Title or Position:
DOCTOR OUDEH
Authorized Official Telephone Number:
910-292-2070

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  34428 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 011KY . This is a "GROUP BCBS NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89011KY , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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