Provider Demographics
NPI:1205893245
Name:ISMAIL, HABIB ALI (MD)
Entity type:Individual
Prefix:
First Name:HABIB
Middle Name:ALI
Last Name:ISMAIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1330 W COVINA BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3200
Mailing Address - Country:US
Mailing Address - Phone:909-592-2145
Mailing Address - Fax:909-599-6217
Practice Address - Street 1:1330 W COVINA BLVD
Practice Address - Street 2:STE 103
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3200
Practice Address - Country:US
Practice Address - Phone:909-592-2145
Practice Address - Fax:909-599-6217
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA435232084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A43523Medicaid
CA00A43523Medicare PIN
CA00A43523Medicaid