Healthcare Provider Details

I. General information

NPI: 1811944598
Provider Name (Legal Business Name): IRENY I. IBRAHIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 E COOLEY DR
COLTON CA
92324-3905
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-4179
  • Fax: 909-796-4158
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA64541
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: