Provider Demographics
NPI:1417062712
Name:IBRAHIM, IHAB (MD)
Entity type:Individual
Prefix:
First Name:IHAB
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:IHAB
Other - Middle Name:IBRAHIM GAD
Other - Last Name:IBRAHIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8017
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:77 CASA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5803
Practice Address - Country:US
Practice Address - Phone:805-269-1500
Practice Address - Fax:805-269-1585
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WATD60482949207R00000X
HIMD-7946207R00000X
CAA49412207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1417062712Medicaid
HIF38640Medicare UPIN