Provider Demographics
NPI:1497289342
Name:IBRAHIM, MINA AZIZ (MD)
Entity type:Individual
Prefix:DR
First Name:MINA
Middle Name:AZIZ
Last Name:IBRAHIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HIGHLAND AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1522
Mailing Address - Country:US
Mailing Address - Phone:973-429-7600
Mailing Address - Fax:
Practice Address - Street 1:123 HIGHLAND AVE STE 202
Practice Address - Street 2:
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-1522
Practice Address - Country:US
Practice Address - Phone:973-429-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11703000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery