Provider Demographics
NPI:1801983127
Name:IBRAHIM, MARY (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 BENTLEY AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-1702
Mailing Address - Country:US
Mailing Address - Phone:201-434-9110
Mailing Address - Fax:201-918-5118
Practice Address - Street 1:130 BENTLEY AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-1702
Practice Address - Country:US
Practice Address - Phone:201-434-9110
Practice Address - Fax:201-918-5118
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04200100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC55514Medicare UPIN