Provider Demographics
NPI:1770578601
Name:TANGOREN, IBRAHIM AHMAD (MD)
Entity type:Individual
Prefix:DR
First Name:IBRAHIM
Middle Name:AHMAD
Last Name:TANGOREN
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 1:2949 ERIE BOULEVARD EAST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1460
Mailing Address - Country:US
Mailing Address - Phone:315-579-9037
Mailing Address - Fax:315-424-1779
Practice Address - Street 1:2949 ERIE BOULEVARD EAST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1460
Practice Address - Country:US
Practice Address - Phone:315-579-9037
Practice Address - Fax:315-424-1779
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209386207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01899210Medicaid
NYG77945Medicare UPIN
NY01899210Medicaid