Healthcare Provider Details

I. General information

NPI: 1649433111
Provider Name (Legal Business Name): MOHAB M IBRAHIM MD., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2008
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 N CAMPBELL AVE DEPT OF ANESTHESIOLOGY
TUCSON AZ
85724-5114
US

IV. Provider business mailing address

1501 N CAMPBELL AVE PO BOX 245114
TUCSON AZ
85724-5114
US

V. Phone/Fax

Practice location:
  • Phone: 520-626-7195
  • Fax: 520-626-6066
Mailing address:
  • Phone: 520-626-7195
  • Fax: 520-626-6066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number14808
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number14808
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number47840
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number47840
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: