1740364926 NPI number — DR. NIZAR ISA IBRAHIM M.D.

Table of content: DR. NIZAR ISA IBRAHIM M.D. (NPI 1740364926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740364926 NPI number — DR. NIZAR ISA IBRAHIM M.D.

Organization/Personal Information

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

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:
1740364926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25285 JACLYN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORENO VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92557-5707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-243-1165
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24490 SUNNYMEAD BLVD
Provider Second Line Business Practice Location Address:
STE 117
Provider Business Practice Location Address City Name:
MORENO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92553-7734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-242-9595
Provider Business Practice Location Address Fax Number:
951-247-2577
Provider Enumeration Date:
10/25/2006

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: 207Q00000X , with the licence number:  A70310 , 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: 00A703100 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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