Provider Demographics
NPI:1548963671
Name:MOUSSAOUI, IBRAHIM (DO)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:
Last Name:MOUSSAOUI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 CLEM RD
Mailing Address - Street 2:
Mailing Address - City:BLODGETT
Mailing Address - State:OR
Mailing Address - Zip Code:97326-9713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4311 CLEM RD
Practice Address - Street 2:
Practice Address - City:BLODGETT
Practice Address - State:OR
Practice Address - Zip Code:97326-9713
Practice Address - Country:US
Practice Address - Phone:575-479-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program