Healthcare Provider Details

I. General information

NPI: 1811291503
Provider Name (Legal Business Name): FAHMY IBRAHIM MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 CLAUS ROAD
MODESTO CA
95355
US

IV. Provider business mailing address

PO BOX 576649
MODESTO CA
95357-6649
US

V. Phone/Fax

Practice location:
  • Phone: 209-557-6300
  • Fax: 209-555-7638
Mailing address:
  • Phone: 209-571-8330
  • Fax: 209-491-7148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: FAHMY IBRAHIM
Title or Position: OWNER
Credential: M.D.
Phone: 718-300-5714