Provider Demographics
NPI:1548261472
Name:BOHSALI, IBRAHIM (MD)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:BOHSALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 NEBRASKA AVE
Mailing Address - Street 2:STE 1-D
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4864
Mailing Address - Country:US
Mailing Address - Phone:772-464-8707
Mailing Address - Fax:
Practice Address - Street 1:2215 NEBRASKA AVE
Practice Address - Street 2:STE 1-D
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4864
Practice Address - Country:US
Practice Address - Phone:772-464-8707
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0017794207Y00000X, 207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Not Answered207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
56060Medicare ID - Type Unspecified
D56743Medicare UPIN