Provider Demographics
NPI:1902093545
Name:IBRAHIM, JOSEPH ABDELLATIF (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ABDELLATIF
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W UNDERWOOD ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1122
Mailing Address - Country:US
Mailing Address - Phone:407-649-6884
Mailing Address - Fax:407-245-7059
Practice Address - Street 1:77 W UNDERWOOD ST
Practice Address - Street 2:STE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1122
Practice Address - Country:US
Practice Address - Phone:407-649-6884
Practice Address - Fax:407-245-7059
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN438192086S0127X, 208600000X
FLME1110762086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004240700Medicaid
FLME111076OtherMEDICAL LICENSE
FLFR006ZMedicare PIN