Provider Demographics
NPI:1144970153
Name:IBRAHIM, FADY R (DO)
Entity type:Individual
Prefix:
First Name:FADY
Middle Name:R
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-853-2395
Mailing Address - Fax:509-865-0757
Practice Address - Street 1:602 E NOB HILL BLVD
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-3534
Practice Address - Country:US
Practice Address - Phone:509-248-3334
Practice Address - Fax:509-865-0757
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAOP61459797207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2213746Medicaid