Provider Demographics
NPI:1205955549
Name:IBRAHIM, KHAMIS WAJDI (DC)
Entity type:Individual
Prefix:DR
First Name:KHAMIS
Middle Name:WAJDI
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 STONE MOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4426
Mailing Address - Country:US
Mailing Address - Phone:770-482-1114
Mailing Address - Fax:770-484-1206
Practice Address - Street 1:3081 STONE MOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4426
Practice Address - Country:US
Practice Address - Phone:770-482-1114
Practice Address - Fax:770-484-1206
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006698111N00000X
FLCH 8106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor