Provider Demographics
NPI:1649439399
Name:MIAN, IBRAHIM MOHAMMAD (MD)
Entity type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:MOHAMMAD
Last Name:MIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MOHAMMAD
Other - Middle Name:IBRAHIM
Other - Last Name:MIAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:233 BROADWAY RM 1750
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10279-1802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:580-297-9296
Practice Address - Street 1:233 BROADWAY RM 1750
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10279-1802
Practice Address - Country:US
Practice Address - Phone:336-671-5041
Practice Address - Fax:580-297-9296
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-07
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277398207Q00000X, 207Q00000X
GA64643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY277398OtherNEW YORK LICENSE
GA64643OtherGA LICENSE
PAMD438383OtherPA LICENSE
CAA 117962OtherCA LICENSE
IL036127455OtherIL LICENSE