Healthcare Provider Details

I. General information

NPI: 1154783397
Provider Name (Legal Business Name): ABDULLAH IBISH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ABDULLAH IBISH MD

II. Dates (important events)

Enumeration Date: 03/27/2016
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17360 BROOKHURST ST
FOUNTAIN VALLEY CA
92708-3720
US

IV. Provider business mailing address

17360 BROOKHURST ST
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 662-772-4000
  • Fax: 901-227-3206
Mailing address:
  • Phone:
  • Fax: 901-227-3206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA168155
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number31762
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: